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

Anderson, Wendy G.; Chase, Rebecca; Pantilat, Steven Z.; Tulsky, James A.; Auerbach, Andrew D.

doi:10.1007/s11606-010-1568-6

Cited by 127 publications

(134 citation statements)

References 37 publications

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“…This deficiency is not limited to trainees. A study of attending hospitalists showed a similar poor performance 10 . Data further reveal that inadequate training leads to discomfort on the part of interns and residents when discussing these very important issues 11 .…”

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confidence: 88%

Aligning Patient Preferences and Patient Care at the End of Life

Dunn

Litrivis

2011

J GEN INTERN MED

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S tudies have shown that patients' priorities for quality care during advanced illness and at the end of life include consistent and reliable medical information, expert pain and symptom management, avoiding inappropriate prolongation of the dying process, relieving burdens on loved ones, and being prepared for death. [1][2][3][4] Despite patients' focus on quality of life issues, the majority of current Medicare spending is allocated towards hospital care, 1 and a significant proportion of this expenditure goes towards costly "cure-driven" interventions at the end of life. In an effort to deliver treatment plans that are concordant with patients' priorities, identification of patients' goals of care and alignment with medical delivery is critical.Mounting evidence suggests that addressing goals of care is directly linked with higher quality. A recent study, for example, revealed that a lack of "end-of-life" discussions in the hospital setting was associated with escalations in care in the last weeks of life and worse overall rated quality of care 4 . In this issue of JGIM, Yuen and colleagues 5 describe existing barriers and propose methods to facilitate earlier and more efficient discussions of cardiopulmonary resuscitation preferences in the inpatient setting.To ensure high quality care during advanced illness and at the end of life, educational initiatives and assessment methods focused on improving communication skills coupled with system changes need to be implemented.Guidelines for addressing cardiopulmonary resuscitation preferences with patients and surrogate decision makers have been formulated by experts in the field of palliative care. [6][7][8] The recommended steps include discussing and clarifying any misconceptions about the current medical condition and prognosis, eliciting goals and values for care, and discussing code status in a manner that adheres to the criteria for informed consent and if necessary making a physician recommendation. Yet this strategy is rarely followed in practice 9,10 . While core measures for the management of common medical conditions, such as aspirin administration after a myocardial infarction, have improved standards of care, delineating the required key elements in this communication process would be an important step for accrediting bodies and hospitals.Educating trainees will be essential in ensuring that these communication guidelines are utilized in patient encounters. Despite the fact that housestaff frequently address code status, these conversations are often brief, and do not elicit the patient's understanding of their prognosis or explore the patient's goals and values. Additionally, they rarely meet criteria for informed consent 9 . This deficiency is not limited to trainees. A study of attending hospitalists showed a similar poor performance 10 . Data further reveal that inadequate training leads to discomfort on the part of interns and residents when discussing these very important issues 11 . Mandatory formal curricula addressing this important skill se...

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confidence: 88%

Aligning Patient Preferences and Patient Care at the End of Life

Dunn

Litrivis

2011

J GEN INTERN MED

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“…18 This may be because deliberate practice rarely occurs in clinical settings or because mistakes are passed down from faculty to learners. 19 Effective health care communication has been linked to improved patient care. 20,21 Our findings suggest that these skills will not develop in the absence of high-quality educational programs and rigorous assessment measures.…”

Section: Discussionmentioning

confidence: 99%

Code Status Discussion Skill Retention in Internal Medicine Residents: One-Year Follow-Up

Wayne

Moazed

Cohen

et al. 2012

Journal of Palliative Medicine

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Background: Communicating with patients about goals of care is an important skill for internal medicine residents. However, many trainees are not competent to perform a code status discussion (CSD). A multimodality intervention improved skills in a group of first-year residents in 2011. How long these acquired CSD skills are retained is unknown. Objective: To study CSD skill retention one year after a multimodality intervention. Design: This was a longitudinal cohort study. Setting/Subjects: Thirty-eight second-year internal medicine residents in a university-affiliated internal medicine residency program participated in the study. Nineteen completed the intervention and 19 served as controls. Measurements: Mean CSD clinical skills examination (CSE) scores using an 18-item checklist were compared after the intervention (2011) and one year later (2012). Results: Intervention group residents performed significantly better than residents in the control group (71.9% (standard deviation [SD] = 16.0%) versus 54.7% (SD = 17.1%; p < 0.001) at one-year follow-up. Intervention group residents retained their CSD skills at one year as performance was 75.1% in 2011 and 71.9% in 2012 ( p = 0.46). Control group residents did not develop additional CSD skills as 2011 checklist performance was 53.2% and 2012 performance was 54.7% ( p = 0.78). Conclusions: CSD skills taught in a rigorous curriculum are retained at one-year follow-up. Residents in the control group did not acquire new CSD skills despite an additional year of training and clinical experience. Further study is needed to link improved CSD skills to better patient care quality.

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“…Clinicians spend strikingly little time on these important decisions and fail to cover essential issues. 57 Discussions seem to be unstructured and without clear objectives. 69 Physicians do not reliably provide appropriate prognostic information, 35,57 offer recommendations, focus on life goals, 57 or address adverse functional and cognitive outcomes.…”

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confidence: 99%

“…57 Discussions seem to be unstructured and without clear objectives. 69 Physicians do not reliably provide appropriate prognostic information, 35,57 offer recommendations, focus on life goals, 57 or address adverse functional and cognitive outcomes. 30 Thus, physicians require educational programs that focus on communication skills.…”

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confidence: 99%

The Need for Safeguards in Advance Care Planning

Billings

2012

J GEN INTERN MED

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The recent uproar about Medicare "death panels" draws attention to public and professional concerns that advance care planning might restrict access to desired life-sustaining care. The primary goal of advance care planning is to promote the autonomy of a decisionally incapacitated patient when choices about life-sustaining treatments are encountered, but the safety of this procedure has not received deserved scrutiny. Patients often do not understand their decisions or they may change their mind without changing their advance care directives. Likewise, concordance between patients' wishes and the understanding of the physicians and surrogate decision makers who need to represent these wishes is disappointingly poor. A few recent reports show encouraging outcomes from advance care planning, but most studies indicate that the procedure is ineffective in protecting patients from unwanted treatments and may even undermine autonomy by leading to choices that do not reflect patient values, goals, and preferences. Safeguards for advance care planning should be put in place, such as encouraging physicians to err on the side of preserving life when advance care directives are unclear, requiring a trained advisor to review non-emergent patient choices to limit life-sustaining treatment, training of clinicians in conducting such conversations, and structured discussion formats that first address values and goals rather than particular life-sustaining procedures. Key targets for research include: how to improve completion rates for person wanting advance care directives, especially among minorities; more effective and standardized approaches to advance care planning discussions, including how best to present prognostic information to patients; methods for training clinicians and others to assist patients in this process; and systems for assuring that directives are available and up-to-date.

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

Cited by 127 publications

References 37 publications

Aligning Patient Preferences and Patient Care at the End of Life

Aligning Patient Preferences and Patient Care at the End of Life

Code Status Discussion Skill Retention in Internal Medicine Residents: One-Year Follow-Up

The Need for Safeguards in Advance Care Planning

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