Code Status Preferences Research Articles

Developing a Policy for Do Not Resuscitate Orders Within a Framework of Goals of Care

Discussions about DNR (do not resuscitate) orders or code status are common but can be difficult and may not lead to accurate understanding between clinicians and patients. These discussion are often isolated from the larger context of a patient's plan of care. Addressing patients goals of care, which provide a basic orientation for clinical and ethical decision making, may improve clinicians' understanding about patients' code-status preferences. On the basis of experience at the University of Iowa Hospitals and Clinics, which entailed incorporating goals of care in ethics education, identifying six goals of care through a structured literature review, surveying hospitalized adults, and integrating goals of care into palliative care education, the University of Iowa Hospitals and Clinics ethics committee revised the hospital policy regarding DNR orders. The intention was to avoid treating DNR orders as an isolated clinical phenomenon and to instead place the discussion of DNR orders in the more general context of end-of-life discussions and to place both of these discussions within an even more general framework of goals of care. The DNR order policy represents an effort to translate conceptual analysis, empirical research, and clinical experience into hospital policy so that clinicians are encouraged to place code-status discussions within a larger, goal-oriented context. Using goals of care to guide decision making about DNR orders and other treatments should enhance the quality of patient care by improving the fit between the biomedical information we provide patients and the values our patients rely on to make their medical decisions.

Code Status Discussions: Agreement Between Internal Medicine Residents and Hospitalized Patients

Background: Medical residents frequently participate in code status discussions, yet their competency in this role has not been evaluated. Purpose: The objective is to determine the quality of code status discussions from the perspective of both resident and patient. Methods: We conducted a cross-sectional survey of consecutive pairs of hospitalized patients and admitting residents at Mayo Clinic in March 2007. We measured perceptions of occurrence and content of code status discussions, admission volume, and demographic information. Results: Among the 41 matched pairs, residents and patients agreed that a code status conversation occurred in 63% of cases. Agreement was more likely if residents performed less than 4 admissions ( p= .02). Patients reported the inclusion of specific discussion components, such as resuscitation procedures (7%) and outcomes (0%), less frequently than residents (71% and 27%, respectively, p< .001). Conclusions: Residents and patients demonstrated poor agreement on the occurrence and components of code status conversations. Residency programs should identify ways to enhance residents’ competency in eliciting patients’ code status preferences and provide adequate time for code status discussions.

Code Status Documentation in the Outpatient Electronic Medical Records of Patients with Metastatic Cancer

Advanced care planning (ACP) is considered an essential component of medical care in the United States, especially in patients with incurable diseases. However, little is known about clinical practices in outpatient oncology settings related to discussing end-of-life care and documenting code status preferences in ambulatory medical records. To assess the rate of documentation of code status in the electronic longitudinal medical records (LMR) of patients with metastatic cancer. Retrospective review of 2,498 patients with metastatic solid tumors at an academic cancer center. An electronic patient database and the LMR were queried to identify demographic information, cancer type, number of clinic visits, and documentation of code status. The sample consisted of adult patients with metastatic prostate, breast, ovarian, bladder kidney, colorectal, non-colorectal gastrointestinal (GI), and lung cancers. Primary outcome was the percentage of documented code status in the LMR. Among the 2,498 patients, 20.3% had a documented code status. Code status was designated most frequently in patients with non-colorectal GI (193/609, 31.7%) and lung (179/583, 30.7%) cancers and least frequently in patients with genitourinary malignancies [bladder/kidney (4/89, 4.5%), ovarian (4/93, 4.3%), and prostate (7/365, 1.9%) cancers]. Independent predictors of having documented code status included religious affiliation, cancer type, and a greater number of visits to the cancer center. Younger patients and black patients were less likely to be designated as DNR/DNI. Despite the incurable nature of metastatic cancer, only a minority of patients had a code status documented in the electronic medical record.

Code status discussions and goals of care among hospitalised adults

Background and objective:Code status discussions may fail to address patients’ treatment-related goals and their knowledge of cardiopulmonary resuscitation (CPR). This study aimed to investigate patients’ resuscitation preferences, knowledge of CPR...

Code status documentation in the outpatient electronic medical records of patients with metastatic cancer

9576 Background: Advanced care planning is an essential component of cancer care for patients with incurable malignancies. However, the extent to which clinicians clearly document end-of-life care discussions and code status preferences in ambulatory medical records is unknown. The goal of the study was to investigate the rate of code status documentation in the electronic longitudinal medical record (LMR) of patients with metastatic cancers. Methods: We conducted a retrospective review of outpatient medical records of 2498 patients with metastatic solid tumors seen at an academic cancer center from 10/1/06 through 2/29/08. An electronic database was used to gather information on patient demographics, cancer type, and visits to the cancer center. The sample consisted of patients with metastatic breast, colorectal, non-colorectal gastrointestinal (GI), bladder/kidney, ovarian, prostate, and lung cancers. For the study endpoints, we queried the LMR to determine completion and designation of code status, which could be documented as follows: full code, do not resuscitate (DNR)/do not intubate (DNI), or DNR/DNI with specific resuscitation requests. Multiple logistic regression was used to identify independent predictors of code status completion and resuscitation preference. Results: Among the 2498 patients, 508 (20.3%) had a documented code status. Code status was documented more frequently in patients with metastatic non-colorectal GI (193/609, 31.7%) and lung (179/583, 30.7%) cancers compared to patients with genitourinary malignancies (bladder/kidney [4/89, 4.5%], ovarian [4/93, 4.3%] and prostate [7/365, 1.9%] cancers). Independent predictors of having documented code status included cancer type and a greater number of visits to the cancer center. Younger patients and black patients were less likely to be designated as DNR/DNI. Conclusions: Despite the incurable nature of metastatic cancers, a minority of patients had a code status documented in the outpatient medical record. Given the importance of advanced care planning for those with terminal illness, interventions are needed to encourage discussion and documentation of end-of-life care preferences in patients with advanced cancer. No significant financial relationships to disclose.