What Should We Say When Discussing “Code Status” and Life Support with a Patient? A Delphi Analysis

Downar, James; Hawryluck, Laura

doi:10.1089/jpm.2009.0269

Cited by 32 publications

(25 citation statements)

References 26 publications

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“…Advance Care Planning may help reduce this negative response; by normalizing the subject and raising it before an acute illness, physicians may help reduce anxiety and shock when it is raised during a deterioration 18,23 .Both FC and DNR patients emphasized the importance of honesty, clarity, and sensitivity when discussing this issue. Previous studies have highlighted the deficiencies of resuscitation conversations 7,[24][25][26] , and others have proposed techniques to improve them 11,19,25,[27][28][29] .…”

Section: Discussionmentioning

confidence: 99%

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

et al. 2011

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BACKGROUND:The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status. METHODS:We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach. RESULTS:We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia.CONCLUSION: Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

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Section: Discussionmentioning

confidence: 99%

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

et al. 2011

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“…We identified five key CSD quality elements based on published guidelines on CSD content 6 and input from three clinical experts in internal medicine, geriatrics, and palliative medicine, which was supplemented by items from a checklist that we previously developed and evaluated as part of a resident CSD skills training program for discussion of code status. 13 We developed a chart abstraction tool to assess documentation of five quality elements: 1) documentation of who the discussion was held with (“discussant”), 2) discussion of patient goals and/or values, 3) discussion of prognosis, 4) review of treatment options and/or resuscitation outcomes, and 5) identification of a health care power of attorney (HCPOA).…”

Section: Methodsmentioning

confidence: 99%

Documentation Quality of Inpatient Code Status Discussions

Thurston

Wayne

Feinglass

et al. 2014

Journal of Pain and Symptom Management

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Context Accurate documentation of inpatient code status discussions (CSDs) is important because of frequent patient care handoffs. Objective To examine the quality of inpatient CSD documentation and compare documentation quality across physician services. Methods This was a retrospective study of patients hospitalized between January 1 and June 30, 2011 with a new or canceled do-not-resuscitate (DNR) order at least 24 hours after hospital admission. We developed a chart abstraction tool to assess the documentation of five quality elements: 1) who the DNR discussion was held with, 2) patient goals/values, 3) prognosis, 4) treatment options and resuscitation outcomes, and 5) health care power of attorney (HCPOA). Results We identified 379 patients, of whom 235 (62%) had a note documenting a CSD. After excluding patients lacking a note from their primary service, 227 remained for analysis. Sixty-three percent of notes contained documentation of who the discussion was held with. Patient goals/values were documented in 43%, discussion of prognosis in 14%, treatment options and resuscitation outcomes in 40%, and HCPOA in 29%. Hospitalists were more likely than residents to document who the discussion was held with (P < 0.001) and patient goals/values (P < 0.001), whereas internal medicine residents were more likely to document HCPOA (P = 0.04). The mean number of elements documented for hospitalists was 2.40, followed by internal medicine residents at 2.07, and noninternal medicine trainees at 1.30 (P < 0.001). Conclusion Documentation quality of inpatient CSDs was poor. Our findings highlight the need to improve the quality of resident and attending CSD documentation.

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“…to discern if patients know they are dying or not in attempts to determine code status or other preferences regarding the use of life-sustaining treatments. 24,25 However, in this study we found that many patients with lifelimiting illness do not discuss their illness in terms of prognosis. [26][27][28] We also found differences among disease groups in discussions of symptoms and causality.…”

Section: Discussionmentioning

confidence: 60%

What is Your Understanding of Your Illness? A Communication Tool to Explore Patients’ Perspectives of Living with Advanced Illness

et al. 2012

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What Should We Say When Discussing “Code Status” and Life Support with a Patient? A Delphi Analysis

Cited by 32 publications

References 26 publications

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

Documentation Quality of Inpatient Code Status Discussions

What is Your Understanding of Your Illness? A Communication Tool to Explore Patients’ Perspectives of Living with Advanced Illness

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