Factors Influencing Physician Determination of Code Status in the Emergency Department

Abstract

Emergency physicians frequently manage critically ill patients and are expected to determine code status, advanced directives and the level of care expected by patients and families accurately and efficiently. Research has shown that advanced directives and code status do alter treatment decisions in the emergency department (ED), but many emergency physicians do not feel comfortable having this discussion despite research showing no resistance from patients or their families. This may indicate that systemic and educational factors influence an emergency physicians comfort level and ability to determine code status in the ED. This study aims to identify specific barriers to this process. All 82 emergency physicians employed by a 2-hospital urban academic ED were recruited to complete a survey via email. Eighty-nine percent of physicians surveyed participated, including 36 (86%) attendings and 37 (93%) residents. The survey asked emergency physicians to identify their level of training, sources they routinely check and consider valid in determining a patient's code status, barriers to the process, comfort with the paperwork, and level of formal education about the topic. Responses to each question were computed as a percentage of the total number of participants. Subgroups of attendings and residents were also compared. Results indicate that there are significant barriers to efficiently determining code status in the ED. The majority of participants review nursing home notes (99%), contact the health care proxy (93%) or contact the next of kin (78%), but five other sources were also routinely utilized by at least a quarter of participants. Only a legal “Do Not Resuscitate” (DNR) document and speaking with an official health care proxy were considered valid by more than 75% of participants. Twenty-nine percent of participants did not feel comfortable accessing the proper paperwork to make a patient DNR, and only 47% were familiar with the name of the official document for placing these orders in the state where they practice (“MOLST”). Tellingly, only 39% of emergency physicians have received formal didactics on this subject, and 69% have mistakenly intubated and resuscitated a patient they later found to be DNR. Despite no significant difference between residents and attendings who reported receiving formal training about advanced directives (p=0.8092), residents were significantly more likely than attendings to report not being comfortable with proper documentation of code status (p=0.0002) and to cite lack of training as a problem with both in person (p=0.0281) and phone assessment (p =0.0095) of code status. Determining a patient's advanced directives or code status in the ED is a critical task for emergency physicians. The results of this study revealed that emergency physicians are routinely checking multiple sources to determine a patient's code status; however, there is a lack of agreement as to which of these sources is considered valid. Despite consulting multiple sources, many emergency physicians still report resuscitating a patient who had been previously declared DNR. Resident emergency physicians reported lower comfort levels and were more likely to identify lack of formal education as a barrier as compared to attending emergency physicians despite no significant difference between the groups in reported training. Although experience may compensate for lack of training, the results of this study suggest that there could be a role for residency education on this topic.