Processes of code status transitions in hospitalized patients with advanced cancer

Abstract

Background Although hospitalized patients with advanced cancer have low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to Do-Not-Resuscitate (DNR) are unknown. Methods We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes leading to code status order transitions from full code to DNR. Results We reviewed 1047 hospitalizations among 728 patients. Admitting clinicians did not address code status in 53.0% of hospitalizations resulting in code status orders of ‘presumed full’. 275 patients (26.3%) transitioned from full code to DNR and 48.7% (134/275) of those had an order of ‘presumed full’ upon admission but upon further clarification, the patients expressed that they had wished to be DNR prior to the hospitalization. We identified three additional processes leading to order transition from full code to DNR: acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared to discontinuing therapy and education, transitions due to acute clinical deterioration were associated with less patient involvement (P=0.002), shorter time to death (P<0.001), and higher likelihood of inpatient death (P=0.005). Conclusions Half of code status order changes among hospitalized patients with advanced cancer were due to full code orders in patients who had a preference for DNR prior to hospitalization. Transitions due to acute clinical deterioration were associated with less patient engagement and higher likelihood of inpatient death.

Place of death for patients with cancer in the United States, 1999 through 2015: Racial, age, and geographic disparities

“…30 Updated guidelines recommend the integration of specialist palliative care into routine cancer care. 31 Efforts to increase awareness of these services are important, because research has demonstrated that routine assessment of patient values and wishes for end-of-life care is both feasible [32][33][34] and effective at reducing hospital deaths. 35 The Medicare hospice benefit was enacted by Congress in 1982 and provides funding for hospice services 36 ; since that time, hospice has become at least a $15.9-billion business 8 focused on improving end-oflife care.…”

CODE: a practical framework for advancing patient-centred code status discussions

“…A single-centre study of patients with advanced cancer found that one-half of patients with presumed status had a preference for DNR/DNI. 12 We advocate for eliminating presumed Full Code, which can cause harm in certain patients. Instead, healthy, low-risk patients should have a Full Code status, and other patients warrant CSDs.…”

Association of Communication Interventions to Discuss Code Status With Patient Decisions for Do-Not-Resuscitate Orders

“…A recent study 14 in patients with cancer found that physicians document a presumed code status rather than conduct a true discussion, leading to a high proportion of full code status. Almost one-third of patients who were documented as full code would have preferred a do-not-resuscitate (DNR) code status if adequately informed about the consequences of CPR.…”

“…Almost one-third of patients who were documented as full code would have preferred a do-not-resuscitate (DNR) code status if adequately informed about the consequences of CPR. 14 …”