Code Status Discussions Between Attending Hospitalist Physicians and Medical Patients at Hospital Admission

Background: Bioethicists and professional associations have made specific recommendations regarding the content of discussions of CPR. The authors report on quantitative analysis of audio-recordings of discussions of CPR to determine if recommended elements were occurring.

Design and Participants: This was a cross-sectional observational study at two hospitals within a university system between August 2008 and March 2009. Hospitalist physicians and patients who were able to communicate verbally about their medical care were studied. Code status discussions were audio-recorded during the admission encounters with the physician, and these audio transcripts were reviewed. A quantitative content analysis was performed to determine whether discussions included elements recommended by bioethicists and professional associations. Two coders independently coded all discussions.

Results: Audio-recordings of 80 patients’ admission encounters with 27 physicians were obtained. Eleven physicians discussed code status in 19 encounters. Discussions were more frequent in seriously ill patients (OR 4, 95% CI 1.2–14.6), yet 66% of seriously ill patients had no discussion. The median length of the code status discussions was 1 min (range 0.2–8.2). Prognosis was discussed with code status in only one of the encounters. Discussions of patients’ preferences focused on the use of life-sustaining interventions as opposed to larger life goals. Descriptions of CPR as an intervention used medical jargon, and the indication for CPR was framed in general, as opposed to patient-specific scenarios. No physician quantitatively estimated the outcome of or provided a recommendation about the use of CPR.

Commentary: Code status was not discussed at all with 3/4^th of patients being admitted to the hospital. Discussions when they did occur were brief and did not include the elements that bioethicists recommended or provided the information needed for patients to make informed decisions regarding preferences for CPR. This practice did not support patient autonomy.

Bottom Line: More practice changes will be needed on how to systematize with whom and how CPR is discussed during hospital admission. The impact and effectiveness of any practice change needs to be rigorously studied.

Source:  Anderson WG, Chase R, Pantilat SZ, Tulsky JA, Auerbach AD. Code status discussions between attending hospitalist physicians and medical patients at hospital admission. J Gen Intern Med. 2011 Apr;26(4):359-66. doi: 10.1007/s11606-010-1568-6. Epub 2010 Nov 20. PMID: 21104036; PMCID: PMC3055965.