Sheila ModiBest Practices Meeting

November 16, 2011

Code Status:What does it mean?

ObjectivesAssess current beliefsDefine “Code Status”Discuss barriers to appropriate use of code

statusDiscuss possible changes to our current

system of discussing and documenting code status.

Question 1An 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:

A. Cardiovert her. B. Do not perform any electrical shocks, even

if this results in her death.C. Not enough information.

Question 2A 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:A. Intubate her. B. Do not intubate her, even if this results in

her death.C. Not enough information.

Question 3A 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:A. Intubate him.B. Do not intubate him, even if this results in

his death.C. Note enough information.

Question 4A 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:A. Intubate him.B. Do not intubate him, even if this results in

his death.C. Not enough information.

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:

A. Admit to MICU, continue Vancomycin, place central line, start vasopressors, intubate and place on mechanical ventilation.

B. Admit to MICU, continue Vancomycin, place central line, start vasopressors, but do not intubate.

C. Do not admit to MICU as patient has already indicated he does not want these aggressive interventions, even if this results in his death.

D. Not enough information.

Not enough information!

ANSWERS:

Do we really know what code status signifies?A survey of 3rd year medical students

revealed:100% reported they knew what code status

meansOnly 17% reported an “excellent

understanding”.My interpretation of these findings: they

didn’t really know what it meansNot knowing what code status means is a

barrier to appropriate use

Code StatusDesignation 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 periodShould NOT influence other theraputic interventions that

may be appropriate for patientOther 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 ordersShould address the difference between intubating for

respiratory insufficiency and intubating during a cardiac arrest

Pre-arrest periodPre-arrest period may include failing

heart and/or ineffective breathing; and may lead to cardiac or respiratory arrest if management failsPre-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.

Advance DirectivesDon’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 admissionCode status designation is valid only for single

hospitalization; should be re-addressed each time

Partial DNR orders: A hazard to patient safety and clinical outcomes?The practice is clinically and ethically

problematicRespect for patient autonomy may create the

potential for patient harmMedical 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)

Partial DNR ordersA partial DNR order highlights larger

problems:Misunderstanding of the meaning/scope of a

DNR orderMoral 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

Does DNR status affect clinical care?It should NOT, but studies have shown that

it does.This is a barrier to patients choosing DNR

statusStudies have found that interpretations of

what a DNR order means vary considerably between physicians, with implications for the overall course of treatment.

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

•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.

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 functionUse of ACE/ARBsAnticoagulation (if atrial fibrillation present)Smoking cessation counselingUse 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.

Code status should never be used for broader interpretationMultiple studies have shown that

physicians’ ability to predict patient preferences regarding LST based on code status is no better than chanceWe will not know unless we also ask

questions about preferences for LST

Appropriate Code Status/LST DiscussionBuild trust, rapportFramed in terms of the overall goals of

careDistinguish between LST and CPR

Patient-specific informationDiagnosis, treatment, prognosis

Should educate patient on prognosis of CPR (future slide)

Make a recommendation

This takes time!

Code status DiscussionsKaldjian, 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

Appropriate Code Status/LST DiscussionBuild trust, rapportFramed in terms of the overall goals of

careDistinguish between LST and CPR

Patient-specific informationDiagnosis, treatment, prognosis

Should educate patient on prognosis of CPR (next slide)

Make a recommendationThis takes time!

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)

Prognosis with Partial DNR ordersOne study compared patients who

received partial resuscitation to those who received full resuscitation. 23% (104/445 pts) who received full

resuscitation survived until dischargeNo 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)

Prognosis after Mechanical VentilationMany 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 comorbiditiesOne study stratified pts on Charlson Comorbidity

Index: group 1 scored </= 3; group 2 scored >3Group 1: 94.4% were discharged home within 6 monthsGroup 2: 23.4% survived until discharge

Appropriate Code Status/LST DiscussionBuild trust, rapportFramed in terms of the overall goals of

careDistinguish between LST and CPR

Patient-specific informationDiagnosis, treatment, prognosis

Should educate patient on prognosis of CPR (future slide)

Make a recommendation

This takes time!

TimeAnderson, W.G, et. al. Code Status

Discussions Between Attending Hospitalist Physicians and Medical Patients at Hospital AdmissionObservational 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

TimeRoter, 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)

TimeLoertscher, 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 casesAgreement 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%)

TimeDeep, 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 status56 interviews, 28 matched pairsIn 21% (6/28 pairs), participants reported

differing results of the discussion2 patients did not recall having the discussion

EducationMultiple studies show that students and

residents receive minimal education on code status and how to have the discussionThis 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 ordersThe one with education had more comprehensive

plansThe effect of this education was sustained for 3

years after the education was given

Review of ObjectivesCode status - definedBarriers to appropriate use of code status

Don’t know definition/scopePartial DNR ordersCode status has been shown to mean “less

care”TimeEducation of students and residents

Suggested intervention

POLSTPhysician Orders for Life Sustaining TherapyExpands 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 cardThis standardized medical order form

transfers across care settingsEmergency services, hospitals, primary care

practices, hospices, and nursing facilities

POLSTProgram was developed in Oregon to

overcome the limitations of advance directives and code statusNow also used in other states

www.polst.org

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 practicesCommunication of treatment preferencesDocumentation of LST ordersSymptom assessment and managementUse of LST

Retrospective observational cohort study; looking at residents in nursing facilities

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).

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.

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 reviewOregon nursing facilities

Results: 71% facilities reported using POLST for at least half of

their residentsDNR orders present on 88% of POLST formsOn 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.

My RecommendationsImplement POLST in New Mexico

Do not include section for antibiotic useProvide more education to everyone

Would be necessary in order to implement POLST anyway

Do not allow partial DNR orders

DISCUSSION

References1. Do DT, Ogrinc G. Assessing third year medical students’ understanding of code status. J Palliat Med 2001 Oct

18. [Epub ahead of print]

2. Council on Ethical and Judicial Affairs, American Medical Association: Guidelines for the Appropriate Use of Do-Not-Resuscitate Orders. JAMA 1991; 265: 1868-1871.

3. Loertscher LL, et.al. Cardiopulmonary resuscitation and do-not-resuscitate orders: A guide for clinicians. Am J Med 2010; 123:4-9.

4. Sanders A, et. al. Partial do-not-resuscitate orders: A hazard to patient safety and clinical outcomes? Crit Care Med 2011; 39:14-18.

5. 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.

6. Sulmasy DP, et. al. The quality of care plans for patients with do-not-resuscitate orders. Arch Intern Med 2004; 164:1573-1578.

7. 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.

8. 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.

9. Loertscher LL, et al. Code status discussions: agreement between internal medicine residents and hospitalized patients. Teach Learn Med 2010; 22(4):251-256.

10. 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.

11. Kaldjian LC, et al. Code status discussions and goals of care among hospitalised adults. J Med Ethics 2009; 25:338-342.

12. 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.

13. 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.

14. 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.