WHAT'S YOUR STATUS? RESUSCITATING A DYING DISCUSSION IN PSYCHIATRY

Abstract

Although the Patient Self-Determination Act of 1991 required that all Medicare/Medicaid-certified institutions inform patients about their right to refuse life sustaining treatments like CPR, the medical literature consistently documents a deficit in code status assessment and documentation for patients admitted to the hospital (1). A 2011 study showed that only 9.3% of over 11000 patients had a code status documented within 24 hours of admission to a medical floor (2). While the literature is limited, this deficit appears to be even greater in psychiatric units: a study of about 600 psychiatric and medical inpatients found the rates of code status documentation among psychiatric patients was significantly lower compared to patients admitted to the medical floor (65 vs 96%, p<0.001) (3). As the population continues to age, the appropriate assessment and documentation of code status becomes particularly relevant for older psychiatric patients. Specific challenges relevant to older adults on inpatient psychiatric units include higher cardiac risks due to self-injurious behaviors, neurocognitive deficits and communication barriers. Common psychiatric conditions that may affect capacity in hospitalized psychiatric patients including psychosis, catatonia, delirium, suicidality. Clinicians should be aware that even in the presence of severe psychiatric burden, capacity may be preserved and should not be presumed absent. A resident-driven quality improvement project at Stanford Hospital aimed to improve code status documentation practices will be described. As many trainees lack formal training in these discussions and report underutilization of capacity determination, it is particularly important that the ethical and legal implications of code status assessment and documentation practices are considered. This session will illustrate the clinical relevance of assessing code status in older adults with psychiatric illnesses and provide an overview of the literature on this topic. Strategies for improved code status assessment and documentation practices will be discussed. 1. Yuen JK, Reid MC, Fetters MD. Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med. 2011;26:791–7. 2. Anderson WG, Pantilat SZ, Meltzer D, Schnipper J, Kaboli P, Wetterneck TB, et al. Code status discussions at hospital admission are not associated with patient and surrogate satisfaction with hospital care: results from the multicenter hospitalist study. Am J Hosp Palliat Med. 2011;28:102–8. 3. Warren MB, Lapid MI, McKean AJ, Cha SS, Stevens MA, Brekke FM, et al. Code status discussions in psychiatric and medical inpatients. J Clin Psychiatry. 2015;76:49–53.