We identified and analyzed the content of code status discussions in audio-recordings of admission encounters between 80 patients and 27 attending hospitalists at 2 hospitals within a university system. As to patients with whom physicians discussed code status, our findings mirror past studies: rates of discussions varied between hospitals,16,33
and physicians were more likely to discuss CPR with older and more seriously ill patients,16
yet many patients with serious illness and a higher likelihood of requiring CPR did not have discussions.16–18
The content of the discussions closely resembles resident physicians’ communication about code status.8,10
Discussions were brief and did not include elements recommended by bioethicists and professional associations, particularly: (1) discussion of prognosis and goals for care, and (2) a physician recommendation.1,2,5,6
These findings suggest that physician experience does not affect the content of CPR discussions. Further, despite 15 years of hospital-based initiatives aimed at improving communication about serious illness,9–15
little has changed in how code status is discussed.
Variability in rates of discussions across providers, hospitals, and institutions may reflect lack of clarity in guidelines. The practice of discussing or attempting to discuss code status with all patients at hospital admission, as rates in one of our hospitals suggest, has been reported by residents at academic centers.34
This may be a response to the Patient Self-Determination Act, which requires hospitals to ask patients about and offer to help complete advance directives.35
Ethical and professional association guidelines, however, specifically state that CPR should only be discussed with patients who are at risk for requiring it.1,2
Code status and advanced directives are related, but not synonymous. Advance directives state preferences for care to be provided in the event of terminal, irreversible illness where the patient is unable to communicate their wishes; DNR orders are physician orders that dictate care only during the current hospitalization.1,6,36
Given patient admission volumes, requiring code status discussions with all admitted patients may, in part, cause physicians to have short discussions that do not include the recommended elements.
Short discussions that fail to include the recommended elements engender significant problems. Patients do not understand CPR as an intervention and the decision they are being asked to make,10,17,37
and seriously ill patients overestimate their prognosis,38
as well as survival after CPR.17
Patients who understand their prognosis and the rate of survival after CPR are less likely to desire life-sustaining therapies in general, and CPR specifically.6,38,39
Discussions that do not include the recommended elements yield, at best, a decision for full code, the default without a discussion. At worst, brief discussions may reinforce misinformation about the effectiveness of CPR,40
which may negatively impact future discussions.
The lower rate of discussions at Hospital A may reflect the fact that, at this hospital, residents evaluated, and may have discussed code status with, patients prior to the audio-recorded attending-patient encounter. Should attendings repeat code status discussions if residents have already performed them? While repetition may increase the burden to patients and decrease resident autonomy, the attending is both ethically and legally responsible for writing the DNR order. Prior studies raise concern that resident CPR discussions are ineffective at promoting patient autonomy.8,10
Thus, we believe that an independent attending-patient discussion of code status is particularly warranted for patients who request DNR status and/or who the attending feels are likely to require CPR or have a poor outcome from it. Involving trainees in these discussions is an opportunity for modeling best-practice discussions.
How can we improve the quality of code status discussions? Past studies have cited deficiencies in medical training as a barrier to communication about end-of-life issues.33,41–44
Gaps are apparent at conceptual and skill levels. Accurately assessing and communicating prognosis appear particularly challenging for physicians.45
This creates a bias toward seriously ill patients receiving CPR, as they are less like to refuse it if they do not understand their prognosis.6,38,39
Residents report not getting feedback on code status discussions,42
and feel uncomfortable with such aspects as making a recommendation about CPR and handling patients’ emotional responses.10
Similarities observed between the content of attendings’ and residents’ communication indicate that trainees learn by modeling and are not exposed to code discussions that meet recommendations. In the outpatient setting, research described best practices for advance care planning by observing discussions of experts in bioethics and communication.30
This approach should be adapted to the inpatient setting, to describe how to accomplish recommendations for discussing code status. Communication-training programs should then be designed using proven methods to teach these skills.46–48
Further research should focus on patient perceptions of the utility and relevance of ethical and professional association recommendations. It is unclear whether patients would have a clearer understanding of CPR after discussions that incorporate expert recommendations. This should be empirically evaluated, along with outcomes as to the decisions patients ultimately make and whether care is then better aligned with their goals and values. Systems-level interventions to support best-practice CPR discussions are needed. The admission encounter is a particularly challenging interaction for hospitalists, who are meeting patients for the first time, often after patients have interacted with a number of other providers. Hospitalists must immediately build rapport with the patient and discuss the medical plan along with patient concerns. These tasks require a significant amount of time, and adding a code status discussion that includes goals, values, prognosis, and a recommendation may be particularly challenging. Further, discussions of prognosis and life-sustaining therapies should be informed by input from outpatient primary care and specialist providers such as oncologists; however, reaching them in advance of the admission encounter is often not possible.
Our study has several limitations. First, we only captured communication in the initial attending-patient encounter and did not review patients’ medical records for documentation of prior code status discussions. The discussions we audio-recorded may have been brief because the attending was verifying a decision that was made during a past hospitalization, with an outpatient physician, or with a resident, although no attending referred to such a discussion. It is also possible that attendings had more prolonged discussions in a subsequent encounter. Discussions for seriously ill patients may have been deferred to specialists such as oncologists or palliative care physicians. Second, we did not record a number of encounters because we were unable to screen all patients before the attending encounter or because physicians declined participation on certain days or with certain patients. Physicians who were newer to the medical service or who were experiencing a busy clinical day were most likely to decline audio-recording; yet it is unlikely that physicians in these situations were more likely to discuss code status or to have longer, more involved discussions. Further, we were able to collect at least one audio-recording from all participating physicians who cared for a consenting patient. Third, our results are based on discussions of physicians within one system. Though the consistency of our findings with other studies supports their validity,8,10,22
code status discussions should be studied at other academic and non-academic institutions with larger numbers of physicians.
Our results suggest numerous avenues of intervention to improve the content and delivery of code discussions. There is a need to clarify guidelines, at both national and institutional levels. As a first step, we recommend that efforts target patients who are at high risk for requiring CPR or having an outcome that is worse than average.49,50
Limiting discussions to these patients as opposed to trying to discuss code status with all admitted patients may encourage longer discussions in which prognosis and overall goals of care can be explored.