Use of a standardized code status explanation by residents among hospitalized patients

Abstract

ObjectivesThere is wide variability in the discussion of code status by residents among hospitalized patients. The primary objective of this study was to determine the effect of a scripted code status explanation on patient understanding of choices pertaining to code status and end-of-life care.MethodsThis was a single center, randomized trial in a teaching hospital. Patients were randomized to a control (questionnaire alone) or intervention arm (standardized explanation+ questionnaire). A composite score was generated based on patient responses to assess comprehension.ResultsThe composite score was 5.27 in the intervention compared to 4.93 in the control arm (p=0.066). The score was lower in older patients (p<0.001), patients with multiple comorbidities (p≤0.001), KATZ score <6 (p=0.008), and those living in an assisted living/nursing home (p=0.005). There were significant differences in patient understanding of the ability to receive chest compressions, intravenous fluids, and tube feeds by code status.ConclusionThe scripted code status explanation did not significantly impact the composite score. Age, comorbidities, performance status, and type of residence demonstrated a significant association with patient understanding of code status choices.Practice implicationsStandardized discussion of code status and training in communication of end-of-life care merit further research.

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

“…We removed duplicates (n = 1203) and discarded 5206 studies after examining titles and 559 studies after screening abstracts. Of the remaining 33 full-text articles, 15 studies 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 were eligible for inclusion (eFigure in the Supplement ). Six studies were judged to be at low risk of bias, 4 studies at high risk of bias, and 5 studies at unclear risk of bias.…”

“…Table 1 lists characteristics of the 15 included RCTs. Publication dates ranged from 1999 to 2018, and studies were conducted mostly in the United States (14 trials 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 37 , 38 , 39 , 40 ), with 1 trial 36 from Australia. Across all studies, a total of 2405 participants were included, with study sample sizes ranging from 50 to 313 per trial.…”

“…Across all studies, a total of 2405 participants were included, with study sample sizes ranging from 50 to 313 per trial. In 8 studies, 26 , 27 , 31 , 32 , 33 , 35 , 36 , 39 participants were recruited among hospitalized patients, and a further 5 studies 28 , 29 , 34 , 38 , 40 recruited outpatients, whereas 1 study 37 investigated residents of a nursing facility and 1 study 30 recruited outpatients and hospitalized patients.…”

“…Eight studies 26 , 27 , 28 , 29 , 30 , 34 , 36 , 38 used advanced diseases with a life expectancy less than 1 year, such as metastatic cancer, end-stage congestive heart, or renal failure, as the inclusion criteria, while 7 studies 31 , 32 , 33 , 35 , 37 , 39 , 40 had no exclusion criteria based on illness. The mean age of the study population was 60 years or older in 12 studies.…”

“…Some videos also contained images of real patients being treated on intensive care units, and other videos also provided information regarding end-of-life care or advance directives. 37 , 40 Other studies used designed advance care planning interviews, 30 standardized scripted explanations, 32 , 33 or written information 36 as interventions.…”