Association of code status discussion with invasive procedures among advanced-stage cancer and noncancer patients

Abstract

BackgroundCode status discussion is associated with a decrease in invasive procedures among terminally ill cancer patients. We investigated the association between code status discussion on admission and incidence of invasive procedures, cardiopulmonary resuscitation (CPR), and opioid use among inpatients with advanced stages of cancer and noncancer diseases.MethodsWe performed a retrospective cohort study in a single center, Ito Municipal Hospital, Japan. Participants were patients who were admitted to the Department of Internal Medicine between October 1, 2013 and August 30, 2015, with advanced-stage cancer and noncancer. We collected demographic data and inquired the presence or absence of code status discussion within 24 hours of admission and whether invasive procedures, including central venous catheter placement, intubation with mechanical ventilation, and CPR for cardiac arrest, and opioid treatment were performed. We investigated the factors associated with CPR events by using multivariate logistic regression analysis.ResultsAmong the total 232 patients, code status was discussed with 115 patients on admission, of which 114 (99.1%) patients had do-not-resuscitate (DNR) orders. The code status was not discussed with the remaining 117 patients on admission, of which 69 (59%) patients had subsequent code status discussion with resultant DNR orders. Code status discussion on admission decreased the incidence of central venous catheter placement, intubation with mechanical ventilation, and CPR in both cancer and noncancer patients. It tended to increase the rate of opioid use. Code status discussion on admission was the only factor associated with the decreased use of CPR (P<0.001, odds ratio =0.03, 95% CI =0.004–0.21), which was found by using multivariate logistic regression analysis.ConclusionCode status discussion on admission is associated with a decrease in invasive procedures and CPR in cancer and noncancer patients. Physicians should be educated about code status discussion to improve end-of-life care.

Predictors Associated with Survival Among Elderly In-Patients Who Receive Cardiopulmonary Resuscitation in Japan: An Observational Cohort Study

“…10 In Japan, more than 70% of hospitalized patients are aged ≥ 65 years, approximately three in four die in the hospital, and two in ten do not have DNR orders. 11 In this context, we used a large population-based database from 81 Japanese hospitals to investigate the survival rate after CPR among hospitalized elderly patients and to identify predictors associated with survival.…”

<p>Early DNR Order and Long-Term Prognosis Among Patients Hospitalized for Acute Heart Failure: Single-Center Cohort Study in Japan</p>

“…Furthermore, discussing code status on admission reportedly decreased invasive procedures before death that cancer 25 and non-cancer inpatients in an advanced stage would like to avoid. 26 On admission is not an optimal time to initiate advance care planning; however, we should start advance care planning including code status discussion as soon as possible after admission.…”

Effect of a do-not-resuscitate order on the quality of care in acute heart failure patients: a single-center cohort study

“… 26 It has been reported that DNR discussion occurred less frequently for patients with a noncancer primary diagnosis, including HF, compared with cancer patients. 27 , 28 In cases of chronic HF, patients’ health status declines slowly with occasional acute exacerbation, from which they often recover. 29 , 30 By contrast, patients in the advanced stage of cancer have a more predictable progressive downward trajectory with clear prognosis.…”

“… 36 , 37 End-of-life discussion was associated with a decrease in unnecessary invasive procedures, including central venous catheter placement, intubation with mechanical ventilation, CPR, and increase of opioid use during the advanced stage of illnesses, including HF. 27 Physicians should not delay the initiation of end-of-life discussions with patients with HF to provide better quality of end of life.…”