Code Status Preferences Research Articles

The association of demographic factors and disease stage on palliative care (PC) referral rates and completion of advanced directives in a lung cancer (LC) patient population.

e24150 Background: Early referral to PC improves quality of life among patients with lung cancer and is associated with improvement in overall survival in patients with stage 4 disease. However, PC utilization remains low. Few studies examined the disparities in PC access and use in real life SCLC and NSCLC patient populations. Objective: To determine the prevalence of PC use among a sample of LC patients and assess the role of PC in facilitating directives and goals of care discussion. Methods: A retrospective cohort analysis was conducted utilizing a randomly selected subset of LC patients treated at the IU Simon Comprehensive Cancer Center between 1/1/18 and 12/31/20. We collected information on advanced directives in the form of designated medical decision maker (Healthcare representative or Healthcare power of attorney) and code status preferences (DNR or POST form). Signed DNR order/POST forms information, demographics (sex, race), LC stage, and LC type were analyzed using descriptive analyses. Chart search identified the dates of first palliative care visit and number of total palliative care visits. Results: Patient characteristics (n = 209): Females 51.7%; White 86.7%; NSCLC 88.5%; stage IV 44.1%. The percentage of total patients who were referred to palliative care was 21.1%. No significant difference in referral rates was found between NSCLC and SCLC patients. 22.3% of male patients and 19.8% of female patients were referred to PC (p = 0.61). No difference was noted in the percentage of white and non-white patients referred to PC (21% and 26.1%, p = 0.97). Palliative referral rates and time from diagnosis to first palliative contact was significantly associated with disease stage, as 27.9% of patients with stage 4 were referred to palliative compared to 15.6% of patients with stages 1-3 (p = 0.036); median time from diagnosis to first palliative contact in stage 4 patients was 355.7 days vs 573.7 days in stages 1-3. Disease stage was associated with the median time from diagnosis to signing POST/DNR forms: 213.6 days in stage 4 patients vs. 409.1 days in stage 1-3 patients. Discussing and signing POST/DNR and HCPOA/HCR forms was associated with palliative care referrals; 53.7% and 63.6% of those referred to palliative signed POST/DNR and HCPOA/HCR forms respectively vs. 11.4% and 16.9% for patients who were never referred to PC. Conclusions: Stage 4 LC was associated with higher likelihood of referral to palliative care than stages 1-3 but PC was underutilized in LC. Demographic factors (race, sex) were not significantly associated with PC referral rates. Patients referred to PC were more likely to address advanced directives than patients who were never offered PC. Strategies to increase palliative care utilization and barriers limiting PC utilization in LC patients need to be further investigated.

Health Care System Distrust, Race, and Surrogate Decision-Making Regarding Code Status.

Previous studies have shown that black patients are more likely to prefer life-sustaining treatments such as cardiopulmonary resuscitation at end-of-life (EOL) compared to non-Hispanic white patients. Given prior racial disparities in health care, distrust has been proposed to explain these preferences. As many hospitalized older adults require surrogates to make medical decisions, we explored surrogates' code status preferences and the role of trust in these decisions. We conducted secondary analyses of an observational study of patient/surrogate dyads admitted to three hospitals in a Midwest metropolitan area. Distrust was assessed using the Revised Health Care System Distrust Scale. A single item asked the surrogate which code status they thought was best for the patient, full code or do not resuscitate. We enrolled 350 patient/surrogate dyads (101 black; 249 white). In bivariate analysis, higher proportion of black surrogates preferred full code (62.4% vs. 38.3%, p=0.0001). After adjusting for trust and sociodemographic and psychological covariates, race was still significantly associated with preference for full code (adjusted odds ratio=2.13; 95% confidence interval: 1.16-3.92; p=0.0153). Surrogate race was not associated with distrust in bivariate or multivariable analysis, adjusting for sociodemographic and psychological covariates (p=0.3049). Although black race was associated with preferences for full code status, we observed no association between race and distrust. Differences in code status preference may be due to other factors related to race and culture. To ensure that patients are receiving EOL care that is consistent with their values, more work is needed to understand the cultural complexities behind EOL care preferences.

Code Status Blues: Do Physicians Order Do-Not-Resuscitate (DNR) Less Often Since Texas Enacted DNR Law? (W205A)

1.Explain whether a legally mandated policy change to physician workflow affected an institution’s ability to implement patients’ code status preferences.2.Develop ideas for further research to explore whether creating policies to govern implementation of patients’ wishes actually improves understanding and communication of patients’ wishes among care teams. Respecting patients’ autonomous wishes is crucial to providing quality end-of-life care. Do-Not-Resuscitate (DNR) orders for patients who request them is a critical part of such care. On April 1, 2018, Texas implemented Senate Bill 11. This law mandates extra steps physicians must take to document consent from hospitalized patients prior to ordering DNR. This study investigated whether inpatient DNR order utilization decreased after the law took effect. We conducted a retrospective cohort chart review of all adults admitted to an academic urban tertiary care hospital in Texas during the three years immediately before and the year immediately after the law’s implementation. We reviewed all code status orders for the 5,426 sickest patients. The primary outcome is the proportion of patients who had DNR in effect at the end of their hospitalizations. Before the law went into effect, the proportion of patients with DNR orders was 40.4%; after the law, the proportion of patients with DNR orders dropped to 36.3%, a result that is significant with a p value of 0.004. This study shows a significant decrease in inpatient DNR order utilization in the study institution following the law’s implementation.

The effect of a CPR decision aid on CPR knowledge and code status preferences in patients with recurrent gynecologic malignancies

Objective: It is imperative to assess and improve CPR literacy in order for patients to make informed decisions regarding end-of-life preferences. We assessed the feasibility of a video CPR decision aid administered in the ambulatory setting and its effect on CPR literacy and code status preferences in patients with recurrent gynecologic cancer.

Do Hispanics prefer to be full code at the end of life? The impact of palliative care consults on clarifying code status preferences and hospice referrals in Spanish-speaking patients.

Hispanics often have disparities at the end of life. They are more likely to die full code and less likely to have discussions regarding prognosis and do not resuscitate (DNR)/do not intubate (DNI), despite studies showing Hispanic values comfort over the extension of life. Barriers to patient-centered care include language,socioeconomic status and health literacy. We evaluated the impact of palliative care (PC) consults on the change of code status and hospice referrals, comparing seriously ill Hispanic and non-Hispanic white patients. A retrospective cohort study of all white and Hispanic patients referred to the PC service of a county hospital from 2006 to 2012. We evaluated ethnicity, language, code status at admission and after PC consult, and hospice discharge. Chi-squared tests were used to analyze characteristics among three groups: non-Hispanic white, English-speaking Hispanic, and Spanish-speaking Hispanic patients. Of 925 patients, 511 (55%) were non-Hispanic white, 208 (23%) were English-speaking Hispanic, and 206 (22%) were Spanish-speaking Hispanic patients. On admission, there was no statistically significant difference in code status among the three groups (57%, 64%, and 59% were full code, respectively, p = 0.5). After PC consults, Spanish-speaking Hispanic patients were more likely to change their code status to DNR/DNI when compared with non-Hispanic white and English-speaking Hispanic patients (44% vs. 32% vs. 28%, p = 0.05). Spanish-speaking Hispanic patients were more likely to be discharged to hospice when compared with English-speaking Hispanics and non-Hispanic whites (33%, 29%, and 23%, respectively, p = 0.04). Spanish-speaking Hispanic patients were more likely to change from full code to DNR/DNI compared with non-Hispanic white and English-speaking Hispanic patients, despite similar code status preferences on admission. They were also more likely to be discharged to hospice. PC consults may play an important role in helping patients to align their care with their values and may prevent unwanted aggressive interventions at the end of life.

Is the Emergency Department an Inappropriate Venue for Code Status Discussions?

Historically, it has been assumed that the Emergency Department (ED) is a place for maximally aggressive care and that Emergency Medicine Providers (EMPs) are biased towards life-prolonging care. However, emphasis on early recognition of code status preferences is increasingly making the ED a venue for code status discussions (CSDs). In 2018, our hospital implemented a policy requiring EMPs to place a code status order (CSO) for all patients admitted through the ED. We hypothesized that if EMPs enter CSDs with a bias toward life-prolonging care, or if the venue of the ED biases CSDs towards life-prolonging care, then we would observe a decrease in the percentage of patients selecting DNR status following our institution's aforementioned CSO mandate. We present a retrospective analysis of rates of DNR orders placed for patients admitted through our ED comparing six-month periods before and after the implementation of the above policy. Using quality improvement data, we identified patients admitted through the ED during pre (n=7,858) and post (n=8,069) study periods. We observed the following: after implementation DNR preference identified prior to hospital admission from the ED increased from 0.4% to 5.3% (relative risk (RR) 12.5; 95% CI: 5.2-29.9), defining CS in the ED setting at the time of admission increased from 2.4% to 98.6% (p <0.001), and DNR orders placed during inpatient admission was unchanged (RR=0.97 (95% CI = 0.88-1.07)). Our results suggest that the ED can be an appropriate venue for CSDs.

Impact of Combining a Code Status Order with Admission Orders for Patients Admitted Through the Emergency Department. (TH341D)

•Describe the impact of requiring Emergency Medicine physicians to place a code status order at the time of admission.•Appraise the ability of emergency physicians to identify patients who would select a do not resuscitate code status.•Assess whether adding a mandatory code status order for Emergency Department admissions could benefit your health care system's rates of code status definition at the time of admission. Some have argued that Emergency Physicians (EPs) lack the time, skills, and rapport to effectively engage patients in code status (CS) discussions. And some have claimed that EPs default to full treatment regardless of patient preference. However, identifying patients' code status preference prior to admission can expedite the alignment of treatment with patients' goals of care. In April 2017 we added a mandatory code status order (CSO) for all admissions requested by EPs. To assess EPs' ability to identify patients with “do not resuscitate” (DNR) preferences and to measure the impact of adding a mandatory CSO on the rate of defining CS prior to hospital admission. We identified 17,884 patients admitted through our ED during two study periods: Sep 2017-Mar 2018 (n=8850) and May 2018-Nov 2018 (n=9034). The first CSO identified in the ED and inpatient setting were classified as missing, full code, other code, or DNR. Differences between cohorts were measured through chi-squared tests. We evaluated the relative risk (RR, 95% CI) of identifying DNR preference in the ED between the time periods. There were no significant differences in age, gender, ethnicity, religion, acuity, and in-hospital mortality between cohorts. Compared to the pre-intervention period, defining CS at the time of admission increased from 1.3% to 96.8% (p <0.001), identifying DNR preference prior to admission increased from 0.4% to 4.8% (p <0.001), overall rate of DNR orders in the inpatient setting was unchanged (8.9% pre, 8.8% post, p=0.787). After our intervention DNR preference was 12.8 times more likely to be identified prior to hospital admission (95% CI = 5.3-31.0). These data suggest that adding a code status order to Emergency Department admission requests can substantially increase the rate of code status definition on admission without diminishing the overall proportion of admitted patients electing to be DNR.

When See One, Do One, Teach One Isn't Enough: Assessing Internal Medicine Residents' Code Status Communication Training Needs (S734)

•Explain the lack of training that residents have with regards to code status communication.•Describe the approaches that residents utilize and the obstacles they face when conducting code status discussions. While resident physicians may independently elicit a patient's code status preference starting on their first day of training, limited prior research has examined residents' code status discussion training and approaches. 1.) Describe residents' code status communication training and readiness to lead a code status discussion. 2.) Assess residents' communication approaches when discussing code status. All residents in the internal medicine and medicine-pediatrics program at one academic medical center received an online, anonymous survey in March 2019 with two follow-up prompts and without incentives. Eighty-one residents (79%) completed the survey. Sixty-eight percent did not receive code status training during medical school, and on their first day of residency, 13% felt prepared to discuss code status on the day of admission. Three quarters of residents received no formal training during residency and less than half (39%) were observed and received feedback from a supervising physician after conducting a discussion. Eighty percent agree that additional training would be beneficial. While the majority (53%) of residents agree that physicians should offer code status recommendations to patients, 56% rarely or never give recommendations themselves on the day of admission. Most (81%) rarely or never estimate the in-hospital survival rate after a code. Specific language used by residents in the majority of their code status discussions includes “tube down the throat” (87%) and “re-starting your heart” (77%). Residents cited risk of “rib-breaking” (33%) and “painful shocks” (28%) less frequently. There were no significant differences in communication associated with residents' year of training. Most physicians begin training unprepared to conduct code status discussions and do not receive skills-based education with direct observation during residency. Residents' code status communication practices fail to promote shared decision-making due to language that risks misinforming or coercing patients and families.

Health Care System Distrust, Race, and Surrogate Decision Making Regarding Code Status

Background and Hypothesis: Studies have shown African American patients are more likely to prefer aggressive life-sustaining treatments such as cardiopulmonary resuscitation (CPR) at end-of-life compared to non-Hispanic White patients. Given prior racial disparities in healthcare, low trust has been proposed to explain these preferences. We examined factors that influence surrogate decision makers’ preference for Do Not Resuscitate (DNR) status for hospitalized older adults who cannot make their own medical decisions. We explored whether race is associated with surrogate preference for DNR status for a hospitalized older adult. We also examine if race is associated with distrust and if the race/code status relationship is partially explained (mediated) by distrust in the healthcare system.&#x0D; Experimental Design or Project Methods: Analyses were conducted using data from an observational study of patient/surrogate dyads admitted to an ICU in a Midwest metropolitan area. Distrust was assessed using the Revised Health Care System Distrust Scale. A single item asked the surrogate which status they thought was best for the patient, full code or DNR.&#x0D; Results: In bivariate analysis, higher proportion of African American surrogates showed preference for full code (62.4% vs 37.6%, p=0.0001). After adjusting for trust and sociodemographic and psychological covariates, race was still significantly associated with DNR preference (aOR = 1.92; 95% CI: 1.04, 3.55; p=0.0382). Surrogate race did not show significant association with distrust in bivariate or multivariable analysis, which adjusted for sociodemographic and psychological covariates (p=0.3867).&#x0D; Conclusion and Potential Impact: Contrary to previous studies, we observed no association between surrogate race and distrust of the health care system. Differences in code status preference may be due to other factors related to race and culture. In order to ensure patients are receiving end-of-life care that is consistent with their values, more work is needed to understand the cultural complexities behind end-of-life care preference.

Adherence to Measuring What Matters: Description of an Inpatient Palliative Care Service of an Urban Teaching Hospital.

Benefits of palliative care have been extensively described; however, reports on adherence to national quality indicators are limited. This study focuses on describing the characteristics of patients who were seen at an urban academic hospital and their care team's adherence to 5 out of 10 Measuring What Matters (MWM) quality indicators. Retrospective chart review Setting/Subjects: Patients seen by inpatient palliative care service from January 2014 to December 2015 in an urban academic hospital. Patient age, gender, ethnicity, disease category, discharge end point, life-sustaining preferences, surrogate decision-maker documentation, and initial palliative assessment were analyzed using descriptive, parametric, and nonparametric statistics. During two years, 1272 patients were seen by the inpatient palliative care service. Fifty-one percent of patients were male, with an average age of 68 years. The majority were Caucasian (57%) and African American (41%). Life-limiting illnesses included were cancer, complex chronic illnesses, and gastrointestinal illness. Adherence to comprehensive palliative care assessment was measured at 64%; initial visit assessment for physical symptoms was 38%; code status preference was 99%; care consistent with preference in vulnerable elders was 99%; and surrogate documentation was noted at 33%. Compared to hospital patients discharged without hospice, patients discharged with hospice care had consults with higher adherence to comprehensive assessment and surrogate documentation quality standards (p < 0.05). Adherence to MWM measures was variable. Subjects discharged with hospice services were more likely to receive comprehensive assessment within 5 days of admission and surrogate documentation compared to those subjects without hospice care.

A Randomized Controlled Trial of a CPR Decision Support Video for Patients Admitted to the General Medicine Service.

Patient preferences regarding cardiopulmonary resuscitation (CPR) are important, especially during hospitalization when a patient's health is changing. Yet many patients are not adequately informed or involved in the decision-making process. We examined the effect of an informational video about CPR on hospitalized patients' code status choices. This was a prospective, randomized trial conducted at the Minneapolis Veterans Affairs Health Care System in Minnesota. We enrolled 119 patients, hospitalized on the general medicine service, and at least 65 years old. The majority were men (97%) with a mean age of 75. A video described code status choices: full code (CPR and intubation if required), do not resuscitate (DNR), and do not resuscitate/do not intubate (DNR/DNI). Participants were randomized to watch the video (n = 59) or usual care (n = 60). The primary outcome was participants' code status preferences. Secondary outcomes included a questionnaire designed to evaluate participants' trust in their healthcare team and knowledge and perceptions about CPR. Participants who viewed the video were less likely to choose full code (37%) compared to participants in the usual care group (71%) and more likely to choose DNR/DNI (56% in the video group vs. 17% in the control group) (𝑃 < 0.00001). We did not see a difference in trust in their healthcare team or knowledge and perceptions about CPR as assessed by our questionnaire. Hospitalized patients who watched a video about CPR and code status choices were less likely to choose full code and more likely to choose DNR/DNI.

Hospital Workers' Confidence for End-of-Life Decisions in their Family: A Multicenter Study.

Aims:To study whether health-care workers feel capable of making resuscitation decisions for their own families, the confidence in their family to represent their own preferences, and if some health-care workers feel greater confidence in their ability to undertake such decisions for their family than others.Methods:An anonymous survey conducted among health-care workers of nine institutions in North and Central America. The self-administered questionnaire included demographic and professional characteristics, attitudes, personal preferences, and value judgments on the topic of resuscitation.Results:Eight hundred and fifty-eight surveys were completed; 21.1% by physicians, 37.2% by nurses, and 41.7% by other health-care. Most of the health-care workers (83.5%) stated that they should be unable to determine their own code status and they would allow their family or spouse/significant other to make this decision for themselves. Physicians felt significantly more capable of making a decision regarding the code status of a close family member than other hospital workers (P = 0.019). Professionals who chose to not undergo cardiopulmonary resuscitation were less likely to feel capable of determining the code status of their family.Conclusions:Most of the health-care workers feel capable of making code status decisions for a close family member and most feel equally comfortable having their family or spouse/significant other represent their code status preference should they be incapacitated. There is considerable reciprocity between the two situations. Physicians feel more confident in their ability to make code status decisions for their loved ones than other health-care workers. Regardless of profession, a personal preference for do not attempt resuscitation status is related to less confidence.

When Terminal Illness Is Worse Than Death: A Multicenter Study of Health-Care Providers' Resuscitation Desires.

To investigate how a terminal illness may affect the health-care providers' resuscitation preferences. We conducted a cross-sectional survey in 9 health-care institutions located in 4 geographical regions in North and Central America, investigating attitudes toward end-of-life practices in health-care providers. Statistical analysis included descriptive statistics and χ2 test for the presence of associations ( P < 0.05 being significant) and Cramer V for the strength of the association. The main outcome measured the correlation between the respondents' present code status and their preference for cardiopulmonary resuscitation (CPR) in case of terminal illness. A total of 852 surveys were completed. Among the respondents, 21% (n = 180) were physicians, 36.9% (n = 317) were nurses, 10.5% (n = 90) were medical students, and 265 participants were other staff members of the institutions. Most respondents (58.3%; n = 500) desired "definitely full code" (physicians 73.2%; n = 131), only 13.8% of the respondents (physicians 8.33%; n = 15) desired "definitely no code" or "partial support," and 20.9% of the respondents (n = 179; among physicians 18.4%; n = 33) had never considered their code status. There was an association between current code status and resuscitation preference in case of terminal illness ( P < .001), but this association was overall quite weak (Cramer V = 0.180). Subgroup analysis revealed no association between current code status and terminal illness code preference among physicians ( P = .290) and nurses ( P = .316), whereupon other hospital workers were more consistent ( P < .01, Cramer V = .291). Doctors and nurses have different end-of-life preferences than other hospital workers. Their desire to undergo CPR may change when facing a terminal illness.

Clinician Perspectives on Challenges to Patient Centered Care at the End of Life.

Discussions regarding patient preferences for resuscitation are often delayed and preferences may be neglected, leading to the receipt of unwanted medical care. To better understand barriers to the expression and realization of patients' end of life wishes, a preventive ethics team in one Veterans Affairs Medical Center conducted a survey of physicians, nurses, social workers, and respiratory therapists. Surveys were analyzed through qualitative analysis, using sorting methodologies to identify themes. Analysis revealed barriers to patient wishes being identified and followed, including discomfort conducting end-of-life discussions, difficulty locating patients' preferences in medical records, challenges with expiring do not resuscitate (DNR) orders, and confusion over terminology. Based on these findings, the preventive ethics team proposed new terminology for code status preferences, elimination of the local policy for expiration of DNR orders, and enhanced systems for storing and retrieving patients' end-of-life preferences. Educational efforts were initiated to facilitate implementation of the proposed changes.

Do Hispanics Prefer to be Full Code at the End of Life? The Impact of Palliative Care Consults in Clarifying Code Status Preferences in Spanish-Speaking Patients (S750)

identify at risk inpatients who may benefit from earlier palliative care interventions. Research Objectives. To identify the prevalence of risk factors for geriatric oncology patients associated with increased length of stay, readmission rates, and morbidity. Methods. A protocol was initiated to trigger palliative care consults on patients ages 65 or older admitted to the oncology unit. Patients screened positive if they triggeredwithat least one responseonanine-questionworksheet. 101 geriatric oncology inpatients were screened over a two-year period at our 496 bed, tertiary care, academic, city hospital through the Trigger Program. Results. 98 of 101 patients screened positive and received a palliative care consult. 70 patients (71.4%) did not have an advanced directive, 45 patients (45.9%) did not have a healthcare proxy, 37 patients (37.7%) reported uncontrolled pain, and 33 patients (33.7%) lived alone. 22 of the 33 patients (66.67%) that lived alone did not have a healthcare proxy. The mean number of triggers was 3.25 per patient. Conclusions. Our program elucidated the proportion of geriatric oncology patients without advanced directives and healthcare proxies in our hospital and identified a concern for inadequate treatment of pain in this vulnerable population. We also found that most patients who live alone have not identified a surrogate decision maker. Implications for Research, Policy, or Practice. The extant literature shows that lack of an advanced directive is associated with increased hospital deaths, higher costs, and fewer hospice enrollments. We need to focus our attention on discussing advanced directives in these patients as early as possible to improve outcomes and patient experience. We hope that by triggering consults earlier in their hospital course, we can effectively target this population to improve their symptoms and outcomes.

Patient–physician communication about code status preferences

Code status discussions are important in cancer care, but the best modality for such discussions has not been established. The objective of this study was to determine the impact of a physician ending a code status discussion with a question (autonomy approach) versus a recommendation (beneficence approach) on patients' do-not-resuscitate (DNR) preference. Patients in a supportive care clinic watched 2 videos showing a physician-patient discussion regarding code status. Both videos were identical except for the ending: one ended with the physician asking for the patient's code status preference and the other with the physician recommending DNR. Patients were randomly assigned to watch the videos in different sequences. The main outcome was the proportion of patients choosing DNR for the video patient. A total of 78 patients completed the study, and 74% chose DNR after the question video, whereas 73% chose DNR after the recommendation video. Median physician compassion score was very high and not different for both videos. All 30 of 30 patients who had chosen DNR for themselves and 30 of 48 patients who had not chosen DNR for themselves chose DNR for the video patient (100% versus 62%). Age (odds ratio = 1.1/year) and white ethnicity (odds ratio = 9.43) predicted DNR choice for the video patient. Ending DNR discussions with a question or a recommendation did not impact DNR choice or perception of physician compassion. Therefore, both approaches are clinically appropriate. All patients who chose DNR for themselves and most patients who did not choose DNR for themselves chose DNR for the video patient. Age and race predicted DNR choice.

Documentation of code status at an outpatient academic cancer center: A marker of discussing end-of-life preferences.

307 Background: Documentation of a patient’s code status preference is becoming an increasingly emphasized part of medical care. Hospitals are adopting protocols that encourage code status documentation at the time of admission; however, this requires patients to consider end of life care at a time of acute illness with a practitioner with whom they have little familiarity. We sought to assess the proportion of patients with a documented code status preference in the electronic medical records (EMR) of our outpatient oncology clinics. Methods: The EMR for all patients seen at the Abramson Cancer Center in the months of March, April, and May 2012 were reviewed for the presence of a documented code status and the specific code status designation. The query was limited to patients seen by a medical oncologist and to patients with at least five outpatient visits occurring during or prior to the month being studied. Demographic information regarding patient age, race, religion, medical comorbidities, and oncologic diagnosis including stage were also recorded. Results: A median of 2,071 patients who have had at least five prior visits were seen per month by staff medical oncologists. Of these patients, a median of 49 patients (2%) had a documented code status recorded in the EMR. Patients seen by the thoracic medical oncology group were more likely to have a documented code status (17% vs. &lt;1%); however, these results were not statistically significant (p=0.3173), likely due to extremely small numbers of documentation. Given the low numbers of code status documentation, we were unable to detect an association with any other demographic factor. Conclusions: At our institution, only a small minority of patients with an oncologic diagnosis has documentation of code status in the readily available EMR. This initial analysis emphasizes the need for a larger effort targeted at increasing documentation of code status in the outpatient setting where patients have a longitudinal relationship with their care provider.

Patient-physician communication about code status preferences: A randomized controlled trial.

9049 Background: Code status discussions are important in cancer care. The best modality for such discussions has not been established. Our objective was to determine the impact of a physician ending a code status discussion with a question (autonomy approach) versus a recommendation (beneficence approach) on patients’ do-not-resuscitate (DNR) preference. Methods: Patients in a supportive care clinic watched two videos showing a physician-patient discussion regarding code status. Both videos were identical except for the ending: one ended with the physician asking for the patient’s code status preference and the other with the physician recommending DNR. Patients were randomly assigned to watch the videos in different sequences. The main outcome was the proportion of patients choosing DNR for the video patient. Results: 78 patients completed the study. 74% chose DNR after the question video, 73% after the recommendation video (p=NS). Median physician compassion score was very high and not different for both videos (p=0.73). 30/30 patients who had chosen DNR for themselves and 30/48 patients who had not chosen DNR for themselves chose DNR for the video patient (100% v/s 62%, p&lt;0.001). Age (OR=1.1/year, p=0.01) and white ethnicity (OR=9.43, p=0.004) predicted DNR choice for the video patient. Conclusions: Ending DNR discussions with a question or a recommendation did not impact DNR choice or perception of physician compassion. Therefore, both approaches are clinically appropriate. All patients who chose DNR for themselves and most patients who did not choose DNR for themselves chose DNR for the video patient. Age and race predicted DNR choice.

Aligning Patient Preferences and Patient Care at the End of Life

Aligning Patient Preferences and Patient Care at the End of Life

Code Status Orders and Goals of Care in the Medical ICU

Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care. We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders. Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents' average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status (P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care. Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients' code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.