Hospitalists know that understanding individual preferences about code status is critical to delivering the care patients want. Still, code discussions between doctors and patients don't always happen when they should, or at all. A 2008 study in the Journal of Hospital Medicine found that only 10% of patients in six university-based hospitals had documented code discussions within 24 hours of admission.
Steven Z. Pantilat, FACP, one of the study's authors and director of the palliative care program at the University of California, San Francisco, said he and his co-authors were surprised that variations in physician attitudes, not patient demographics, dictated whether or not these conversations occurred.
“In some hospitals, doctors are just expected to have these conversations. The attending physicians set the attitudes and those attitudes are reflected in the outcomes,” he said. “I expect you would see the same variations between community hospitals that we saw with academic ones.”
Although conversations about code status are important, they don't always go well, according to Eva Chittenden, FACP, director of educational programs at Massachusetts General Hospital at Harvard Medical School in Boston.
“When code discussions go poorly, they can do more harm than good by scaring a patient and making them distrust us,” she said. “It takes time, skill and training to do this right and our system does not really teach us how to do it well.”
When to ask?
The timing of code discussions can be complicated. Dr. Chittenden does not believe they need to occur on admission unless the answer to the question “Would I be surprised if this patient died within the next 72 hours?” is no.
“If the patient is stable and has been admitted for a routine reason, it often can be deferred to someone who actually knows them, such as the primary care physician or oncologist,” she said.
When the need is more immediate, however, she suggested that hospitalists try to develop a rapport with patients first by educating them and their families about their health. Some patients, such as those with Alzheimer's, may not realize their condition could be life-threatening.
“Inquire as to what they understand about their disease and gently correct any misinformation they have. Ask what concerns them as they think about dying,” Dr. Chittenden advised. “We can be afraid to use the word ‘dying’ but some patients are relieved to be able to express their preferences, such as the fact that they do not want to die in the hospital, and we are really doing them a disservice to allow them to be on a path that is not what they really want. “
Sylvia C.W. McKean, FACP, associate professor of medicine at Brigham and Women's Hospital in Boston, generally brings up code status after completing her initial examination, but she stressed that final decisions are rarely made right away.
“I give my treatment plan recommendation for them, then say, ‘You look very well now, but I do not have a crystal ball and I need to know your preferences.’ I tell them we can talk about it now or we can do it later. We can involve the family or primary care doctor or anyone else they want. If English is their second language, I engage a hospital interpreter during these discussions.”
The issue often does not get fully resolved during the hospitalization, Dr. McKean said, and that's OK. “We do not want to force them to make a decision while under stress of being hospitalized. I just let them know that my main goal is to respect their wishes,” she said.
“View this as a process more than a one-time conversation,” Dr. Chittenden said. “Make it about having a dialogue, not about getting certain forms filled out.”
Dr. McKean also pointed out that communicating patients' code status from hospitalist to hospitalist is a sometimes overlooked aspect of the process. She recently came on service and saw a patient listed as full code even though he was wearing a DNR/DNI bracelet. “Someone just made an assumption, but as attending hospitalists, we have a special obligation to get this right,” she said.
Not all or nothing
Sarah Harrington, ACP Member, a specialist in palliative care and hospice in Little Rock, Ark., often cringes when she hears colleagues and residents stumbling through code discussions. She carries copies of a 2006 Journal of Hospital Medicine article on the topic to share (Chittenden EH, Clark ST, Pantilat SZ. “Discussing Resuscitation Preferences with Patients: Challenges and Rewards.” J Hosp Med. 2006;1:231-240).
“We need to do a better job teaching medical students and residents about this,” Dr. Harrington said. “We need to learn to ask open-ended questions and not see it as a dichotomy with black and white answers.”
Diane Meier, FACP, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine in New York, stressed the importance of avoiding end-of-life language in code discussions. Instead, she recommended working to establish care guidelines based on the patient's goals for now and the future.
For example, some patients are focused on being healthy enough to attend an upcoming event, such as a family wedding, she said. Undertaking a treatment such as aggressive new chemotherapy might bring on side effects that jeopardize their ability to attend, a risk that might not be acceptable to them.
“How can they make an informed choice without a special conversation focusing on the benefits and risks of all the available treatment options?” she said. “We can't know their goals unless they tell us.”
Dr. Meier also routinely asks patients what steps they would want her to take if they were to be in a situation in which their body was functioning but their brain was not.
“Some tell me they would want all life-preserving measures taken regardless of their quality of life, while others want only comfort care. I write their answer in the chart verbatim,” she said. She avoids overly specific questions such as “Would you want a ventilator?” because that could limit her ability to care for patients in certain cases, such as pneumonia that is survivable with short-term use of such technology.
“Physicians, as well as patients, sometimes equate DNR with doing nothing, but in fact it can accompany palliative care or hospice or continued aggressive medical treatment,” said Dr. Harrington. “There are many shades of gray, and we need to help our patients see them.”