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  1. Code Status:What does it mean? Sheila Modi Best Practices Meeting November 16, 2011

  2. Objectives • Assess current beliefs • Define “Code Status” • Discuss barriers to appropriate use of code status • Discuss possible changes to our current system of discussing and documenting code status.

  3. Question 1 • An 80 yo F with HTN, hypothyroidism with code status DNR comes to the ED c/o dizziness, SOB, and rapidly deteriorating (unstable) condition. She is unable to talk to you. Cardiac monitoring reveals SVT. Should you: • Cardiovert her. • Do not perform any electrical shocks, even if this results in her death. • Not enough information.

  4. Question 2 • A 68 yo F with asthma and metastatic breast cancer with a code status of DNR comes in with an asthma exacerbation triggered by an accidental exposure to a cat. She has impending respiratory failure. Should you: • Intubate her. • Do not intubate her, even if this results in her death. • Not enough information.

  5. Question 3 • A 75 yo M with severe COPD (FEV1 0.7) with a code status of DNR comes in with a COPD exacerbation and has impending respiratory failure. Should you: • Intubate him. • Do not intubate him, even if this results in his death. • Note enough information.

  6. Question 4 • A 60 yo M with HTN, DM2, and CAD with a code status of DNR comes in with severe multi-lobar PNA and has impending respiratory failure. Should you: • Intubate him. • Do not intubate him, even if this results in his death. • Not enough information.

  7. Question 5 • A 70 yo M with HTN, CKD, CAD, PAD, DM2, and now MRSA PNA and bacteremia who has a documented code status of DNR is on the SAC floor being treated with Vancomycin. Despite abx, his condition deteriorates and he develops septic shock and respiratory distress. He is febrile 39C, hypotensive 85/55, tachycardic 115, tachypneic 28, and his breathing is labored with accessory muscle use. He has not responded to 3L NS. MICU (you) are called to evaluate. When you arrive, patient’s mental status has deteriorated and he is no longer able to coherently answer questions. Should you: • Admit to MICU, continue Vancomycin, place central line, start vasopressors, intubate and place on mechanical ventilation. • Admit to MICU, continue Vancomycin, place central line, start vasopressors, but do not intubate. • Do not admit to MICU as patient has already indicated he does not want these aggressive interventions, even if this results in his death. • Not enough information.

  8. ANSWERS: Not enough information!

  9. Do we really know what code status signifies? • A survey of 3rd year medical students revealed: • 100% reported they knew what code status means • Only 17% reported an “excellent understanding”. • My interpretation of these findings: they didn’t really know what it means • Not knowing what code status means is a barrier to appropriate use

  10. Code Status • Designation of whether or not to perform resuscitation in the event of cardiac and/or respiratory arrest. • Code status holds NO significance in the pre-arrest period • Should NOT influence other theraputic interventions that may be appropriate for patient • Other life-sustaining therapies include: intubation and mechanical ventilation, pressors, ICU transfer, antibiotics, IV fluids, artificial nutrition • Intubation should always be addressed separately, especially in patients with DNR orders • Should address the difference between intubating for respiratory insufficiency and intubating during a cardiac arrest

  11. Pre-arrest period • Pre-arrest period may include failing heart and/or ineffective breathing; and may lead to cardiac or respiratory arrest if management fails • Pre-arrest period scenarios include managing dysrhythmias, ventilatory insufficiency, ineffective gas exchange, respiratory failure • Use of ACLS protocols is not limited to cardiac and respiratory arrest situations; they are also used in the management of pre-arrest conditions and adverse clinical events.

  12. Advance Directives • Don’t really help much because it is often difficult to ascertain when the wishes stated in the advance directive apply and because the wishes indicated are at times too vague to be useful in decision-making • They often fail to take into account a person’s specific medical condition • So, it is still important to have code status discussion at each admission • Code status designation is valid only for single hospitalization; should be re-addressed each time

  13. Partial DNR orders: A hazard to patient safety and clinical outcomes? • The practice is clinically and ethically problematic • Respect for patient autonomy may create the potential for patient harm • Medical treatments are often performed in groupings in order to work effectively. • When such combinations are separated as a result of patient choices, critical elements of life-saving care may be omitted, and the patient may receive non-beneficial or harmful treatment. • A “slow code” is ALWAYS unethical (not intended to be theraputic so is non-beneficial and is misleading to the decision-maker)

  14. Partial DNR orders • A partial DNR order highlights larger problems: • Misunderstanding of the meaning/scope of a DNR order • Moral hazard: providers may inadvertently withhold treatments that are not considered part of a DNR order. This may be inconsistent with patient preferences. • Need for discussions around goals of care

  15. Does DNR status affect clinical care? • It should NOT, but studies have shown that it does. • This is a barrier to patients choosing DNR status • Studies have found that interpretations of what a DNR order means vary considerably between physicians, with implications for the overall course of treatment.

  16. Beach, MC and Morrison RS. The Effect of Do-Not-Resuscitate Orders on Physician Decision Making • A survey involving 3 hypothetical clinical vignettes involving cases with serious life-threatening illnesses was distributed. A series of 10 sequential treatment decisions followed each vignette. Using a 4 point Likert scale, respondents were asked to indicate whether they would initiate these interventions. There were 2 versions of the survey, in one version the patients all had DNR orders. • Physicians agreed or strongly agreed to initiate fewer interventions when a DNR order was present vs. absent

  17. Physicians agreed to initiate fewer interventions when DNR order in place. • Case Mr. M: 4.2 vs 5.0 (p=.008) • Case Mrs. T: 6.5 vs 7.1 (p=.004) • Case Mr. H: 5.7 vs 6.2 (p=.037) • A decrease of 1.0 on this scale represents a 12.5% decrease in the number of interventions that the physicians would initiate. • “The results support the hypothesis that, when presented with identical patient scenarios, physicians will withhold treatments other than CPR for patients with DNR orders.” • Limitation of study: “Not enough information” was not an option in the survey.

  18. Chen, J.L.T., et al. Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure. • Retrospective chart review looking at HF performance measures stratified according to the presence of DNR orders. • HF performance measures included: • Assessment of LV function • Use of ACE/ARBs • Anticoagulation (if atrial fibrillation present) • Smoking cessation counseling • Use of nonpharmacologic strategies, e.g. fluid restriction, diet, alcohol, and exercise. • Conclusion: Patients with DNR orders were less likely to receive diagnostic and treatment therapies for HF according to the ACC/AHA quality measure guidelines.

  19. Code status should never be used for broader interpretation • Multiple studies have shown that physicians’ ability to predict patient preferences regarding LST based on code status is no better than chance • We will not know unless we also ask questions about preferences for LST

  20. Appropriate Code Status/LST Discussion • Build trust, rapport • Framed in terms of the overall goals of care • Distinguish between LST and CPR • Patient-specific information • Diagnosis, treatment, prognosis • Should educate patient on prognosis of CPR (future slide) • Make a recommendation • This takes time!

  21. Code status Discussions • Kaldjian, L.C., et. al. Code status discussions and goals of care among hospitalized adults. • 135 pts interviewed within 48h of admission to a general medicine service • 41 (30.4%) pts had discussed code status with their physician • 116 (85.9%) preferred Full code • 11 (8.1%) patients expressed code status preferences different from the code status documented in their medical record. • Most patients believed it was helpful to discuss goals of care and the chances of surviving in-hospital CPR • 11 (8.1%) pts changed their code status after receiving information about survival following in-hospital CPR • 2 (1.5%) pts changed their code status after discussing goals of care

  22. Appropriate Code Status/LST Discussion • Build trust, rapport • Framed in terms of the overall goals of care • Distinguish between LST and CPR • Patient-specific information • Diagnosis, treatment, prognosis • Should educate patient on prognosis of CPR (next slide) • Make a recommendation • This takes time!

  23. Prognosis after CPR • Studies show that ~15% pts given CPR survive until hospital discharge • Although ~40% survive the initial CPR attempt • Prognosis depends on underlying medical conditions • One study showed that in pts with renal failure only 2% survived until discharge • Another study showed that in pts with metastatic cancer, none survived until discharge • With sepsis, only 1% survived until discharge • No survivors to discharge if CPR lasted >30 min • One study found that 11% of pts who survive initial CPR will undergo CPR at least one other time during hospitalization • Those who do survive to discharge usually do not have severe impairment (were AAOx3), but all had decrease in functional status • Of those who survive to discharge, 25% survive >5 years • Factors for Favorable Prognosis after CPR: Healthy baseline; Younger age; Witnessed arrest; Initial rhythm of v-fib; CPR lasted <10 min; Respiratory arrest (as opposed to cardiac arrest)

  24. Prognosis with Partial DNR orders • One study compared patients who received partial resuscitation to those who received full resuscitation. • 23% (104/445 pts) who received full resuscitation survived until discharge • No patients who received partial resuscitation survived until discharge (0/37 pts) • Partial resuscitation included performing some resuscitative measures while withholding others (24 pts)AND performing all resuscitative efforts for a specified limited time (13 pts)

  25. Prognosis after Mechanical Ventilation • Many pts fear intubation b/c they are unaware of the successful use of short-term mechanical ventilation in certain clinical situations • Studies suggest the most influential factor in survival to discharge for patients with respiratory insufficiency is presence of significant comorbidities • One study stratified pts on Charlson Comorbidity Index: group 1 scored </= 3; group 2 scored >3 • Group 1: 94.4% were discharged home within 6 months • Group 2: 23.4% survived until discharge

  26. Appropriate Code Status/LST Discussion • Build trust, rapport • Framed in terms of the overall goals of care • Distinguish between LST and CPR • Patient-specific information • Diagnosis, treatment, prognosis • Should educate patient on prognosis of CPR (future slide) • Make a recommendation • This takes time!

  27. Time • Anderson, W.G, et. al. Code Status Discussions Between Attending Hospitalist Physicians and Medical Patients at Hospital Admission • Observational study via audio-recordings of 80 pts admission encounters with 27 physicians at 2 hospitals • The median length of the code status discussion was 1 min (range 0.2-8.2 min) • Time constraint is a barrier to adequate discussion

  28. Time • Roter, D.L., et. al. Experts Practice What They Preach: A Descriptive study of Best and Normative Practices in End-of-Life Discussions. • Observational, audio-recordings of outpatient encounters • Experts spent close to twice as much time (14.7 min vs 8.1 min, P<0.001) • Experts were less verbally dominant (P<0.05) • Experts gave less information about procedures and biomedical issues (P<0.05) • Experts engaged more in partnership building (P<0.05) and in more psychosocial and lifestyle discussion (P<0.001) and in more positive talk (P<0.05)

  29. Time • Loertscher, L.L., et. al. Code status discussions: agreement between internal medicine residents and hospitalized patients. • 41 matched pairs (patients and admitting residents) • Residents and patients agreed that a code status conversation occurred in 63% of cases • Agreement was more likely if residents performed less than 4 admissions (P=0.02) • Patients reported the inclusion of specific discussion components less frequently than residents (P<0.001) • Resuscitation procedures (pts 7% vs residents 71%) • Outcomes (0% vs. 27%)

  30. Time • Deep, K.S., et. al. Discussing preferences for cardiopulmonary resuscitation: What do resident physicians and their hospitalized patients think was decided? • Resident physicians, patients + family interviewed following discussion on code status • 56 interviews, 28 matched pairs • In 21% (6/28 pairs), participants reported differing results of the discussion • 2 patients did not recall having the discussion

  31. Education • Multiple studies show that students and residents receive minimal education on code status and how to have the discussion • This is a barrier • One study looked at 2 academic medical centers, one of which provided education to residents about patient care plans for patients with DNR orders • The one with education had more comprehensive plans • The effect of this education was sustained for 3 years after the education was given

  32. Review of Objectives • Code status - defined • Barriers to appropriate use of code status • Don’t know definition/scope • Partial DNR orders • Code status has been shown to mean “less care” • Time • Education of students and residents • Suggested intervention

  33. POLSTPhysician Orders for Life Sustaining Therapy • Expands upon CPR status orders to include orders based on preferences about a range of life-sustaining treatments • Form has orders including: • Code status (CPR status) • Medical interventions • Hospitalization • May include antibiotic use • Artificial nutrition • Form is printed on brightly colored card • This standardized medical order form transfers across care settings • Emergency services, hospitals, primary care practices, hospices, and nursing facilities

  34. POLST • Program was developed in Oregon to overcome the limitations of advance directives and code status • Now also used in other states

  35. www.polst.org

  36. Hickman, SE, et. al. A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physician Orders for Life-Sustaining Treatment Program. • Compare POLST vs. traditional practices • Communication of treatment preferences • Documentation of LST orders • Symptom assessment and management • Use of LST • Retrospective observational cohort study; looking at residents in nursing facilities

  37. Hickman SE, et. al. A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physician Orders for Life-Sustaining Treatment Program. • Results: • Residents with POLST were more likely to have orders about LST preferences beyond CPR than residents without (98.0% vs 16.1%, P<0.001) • No difference between residents with and without POLST in symptom assessment or management • Residents with POLST forms indicating comfort measures only were less likely to receive medical interventions (e.g. hospitalization) than residents with POLST forms indicating full treatment (P=0.004) or residents with traditional DNR orders (P<0.001) or residents with traditional Full code orders (P<0.001).

  38. Hickman, SE, et. al. A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physician Orders for Life-Sustaining Treatment Program. • Discussion: • POLST orders were not associated with the use of antibiotics, despite specific orders addressing abx use. • These findings suggest that the use of standing orders to prospectively make decisions about antibiotics may be an ineffective strategy, perhaps because there is substantial variability in interpretation of when antibiotics should be used to enhance comfort. • Conclusion: Findings suggest that the POLST program offers significant advantages over traditional methods to communicate preferences about LST.

  39. Hickman SE, et. al. Use of the Physician Orders for Life-Sustaining Treatment Program in Oregon Nurstin Facilities: Beyond Resuscitation Status • Telephone survey and on-site POLST form review • Oregon nursing facilities • Results: • 71% facilities reported using POLST for at least half of their residents • DNR orders present on 88% of POLST forms • On forms indicating DNR, 77% reflected preferences for more than the lowest level of treatment in at least one other category. • On forms indicating Full code, 47% reflected preferences for less than the highest level of treatment in at least one other category. • The oldest old (>/= 85 yrs) were more likely than the young old (65-74 yrs) to have orders to limit resuscitation, medical treatment, artificial nutrition and hydration.

  40. My Recommendations • Implement POLST in New Mexico • Do not include section for antibiotic use • Provide more education to everyone • Would be necessary in order to implement POLST anyway • Do not allow partial DNR orders

  41. DISCUSSION

  42. References • Do DT, Ogrinc G. Assessing third year medical students’ understanding of code status. J Palliat Med 2001 Oct 18. [Epub ahead of print] • Council on Ethical and Judicial Affairs, American Medical Association: Guidelines for the Appropriate Use of Do-Not-Resuscitate Orders. JAMA 1991; 265: 1868-1871. • Loertscher LL, et.al. Cardiopulmonary resuscitation and do-not-resuscitate orders: A guide for clinicians. Am J Med 2010; 123:4-9. • Sanders A, et. al. Partial do-not-resuscitate orders: A hazard to patient safety and clinical outcomes? Crit Care Med 2011; 39:14-18. • Chen JL, et. al. Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure. Am Heart J 2008; 156:78-84. • Sulmasy DP, et. al. The quality of care plans for patients with do-not-resuscitate orders. Arch Intern Med 2004; 164:1573-1578. • Anderson WG, et al. Code status discussions between attending hospitalist physicians and medical patients at hospital admission. J Gen Intern Med 2010; 26(4):359-356. • Roter DL, et. al. Experts practice what they preach: A descriptive study of best and normative practices in end-of-life discussions. Arch Intern Med 2000; 160:3477-3485. • Loertscher LL, et al. Code status discussions: agreement between internal medicine residents and hospitalized patients. Teach Learn Med 2010; 22(4):251-256. • Deep KS, et. al. Discussing preferences for cardiopulmonary resuscitation: What do resident physicians and their hospitalized patients think was decided? Patient Education and Counseling 2008; 72:20-25. • Kaldjian LC, et al. Code status discussions and goals of care among hospitalised adults. J Med Ethics 2009; 25:338-342. • Downar J and Hawryluck L. What should we say when discussing “code status” and life support with a patient? A Delphi analysis. J Pall Med 2010; 13(2):185-195. • Hickman SE, et. al. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the Physician Orders for Life-Sustaining Treatment program. J Am Geriatr Soc 2010; 58:1241-1248. • Hickman SE, et. al. Use of the Physician Orders for Life-Sustaining Treatment program in Oregon nursing facilities: beyond resuscitation status. J Am Geriatr Soc 2004; 52:1424-1429.