During residency, Aimee M. Merino, MD, PhD, was alarmed by patients' lack of understanding about code status procedures and outcomes at the end of life. “I don't know of anything else we do that has such a dismal success rate,” she said, noting that only 10% to 18% of resuscitated patients live long enough to leave the hospital. “It just really struck me how much we're doing to people, oftentimes without them having truly given informed consent.”
A fellow resident, Ryan Greiner, MD, ACP Member, had similar concerns. He had worked with the University of Minnesota departments of palliative care and internal medicine to create an informational video for patients, but it hadn't been used since he finished residency and became a hospitalist. Seeing an opportunity, Dr. Merino, now a fellow at the university's department of hematology and oncology, decided to study whether older hospitalized patients who watched the video chose different code statuses than those who received usual care.
How it works
The six-minute video describes and demonstrates patients' code status choices: full code (CPR and intubation if required), do not resuscitate (DNR), and do not resuscitate/do not intubate (DNR/DNI). Dr. Merino, Dr. Greiner, and another colleague randomized 59 patients to watch the video and 60 to receive usual care. The VA has a lengthy approval process for showing videos on patients' TVs, so Dr. Merino used her laptop to show each patient the video.
The hospital's usual practice is for the admitting clinician to discuss code status with all admitted patients, but those conversations vary widely, Dr. Merino said. “Several of my colleagues, their approach to discussing this during their intake, history, and physical is basically to say, ‘If something were to happen, would you want us to do everything we could to save your life?’ and the patient almost always says yes. . . . That's not even really a conversation, and frequently patients don't know exactly what they're agreeing to when the question is phrased that way,” she said.
The researchers found markedly significant differences in code status decisions between patients who saw the video and those who didn't, according to results published online in September 2017 by the Journal of Hospital Medicine. Of those who watched the video, 37% chose full code and 56% chose DNR/DNI, compared to about 71% and 17% of the control group, respectively. About 7% of intervention patients chose DNR, compared to 12% in the control arm.
One challenge of the study was that almost half of the 273 patients who were asked to participate declined. “When people are really sick in the hospital and you go to talk to them about these complex things, sometimes they can't really either cognitively wrap their mind around it or they're just not in a place where they can get into it because they're sick,” said Dr. Merino.
Getting institutional review board (IRB) approval was also a challenge. “I thought, ‘What's the risk of harm here?’ People are watching a video and circling a couple things on a piece of paper. But I was really surprised by how much potential psychological harm was emphasized by the IRB,” she said. “In a way, it made me more determined to do it because I thought this is reinforcing exactly what I've been observing about people not being able to really get the true risks and benefits about this procedure.”
Words of wisdom
One of Dr. Merino's tips for discussing code status is simple: finding a chair and sitting down with the patient. “We all get busy, that's true, but I always consider it to be one of the most important parts of the [history and physical],” she said. “The nice thing about a video is that, once it's made, it really doesn't cost any money, [and] it's pretty easy to disseminate.”
Another tip is that many newly admitted patients aren't sure how much they can trust the care team and may choose full code at first, Dr. Merino said, but they can change their preferences later. “There is a lot of this thought in the population that if you say you don't want resuscitation that you're not going to get treated,” she said. “So I try to get the information out there on that first visit and then leave it open so that they don't feel that I am pressuring them but yet they also know that this is a safe topic to discuss.”
The VA has since completed the video-approval process and is now showing it on the hospital's patient channel, both when doctors choose to show it and when patients request it, said Dr. Merino. “I think it could really revolutionize the way that these things are done by helping to get the information out into the public and counteract these silly things that we see on TV and movies where a person gets two chest compressions and they jump up and run off to save the day after that,” she said. The video is online and available for public use.