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Subramaniam A, Tiruvoipati R, Green C, Srikanth V, Soh L, Yeoh AC, Hussain F, Bailey M, Pilcher D. Frailty status, timely goals of care documentation and clinical outcomes in older hospitalised medical patients. Intern Med J 2021; 51:2078-2086. [PMID: 32892457 DOI: 10.1111/imj.15032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/21/2020] [Accepted: 08/17/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hospitalised frail older patients are at risk of clinical deterioration. Early goals of care (GOC) documentation is vital to avoid futile/unwarranted interventions in the event of deterioration. AIMS To investigate the impact of frailty on timely GOC and its association with clinical outcomes in hospitalised older patients. METHODS This was a single-centre retrospective study of all medical patients aged ≥80 years admitted to the acute medical unit between 1/3/2015 and 31/8/2015, with GOC derived from electronic records. Frailty was measured using the Hospital Frailty Risk Score (HFRS) derived from hospital coding data. Primary outcome compared proportions of timely GOC within 72-h between frail (HFRS ≥ 5) and non-frail (HFRS < 5) patients. Exploratory secondary outcomes included in-hospital mortality, rapid response calls (RRC), prolonged length of stay (LOS) and 28-day readmission rates. RESULTS Of the 1118 admitted patients, 529 (47.3%) were frail. Timely GOC occurred in 50% (559/1118), more commonly in frail patients (283/529, 53.5%) than non-frail patients (276/589, 46.9%), P = 0.027. Frailty was positively associated with timely GOC independent of age and gender (odds ratio = 1.28; 95% confidence interval = 1.01-163; P = 0.041). In univariable analyses, timely GOC was associated with greater in-hospital mortality, RRC, and hospital LOS in both frail and non-frail patients (all P < 0.05) and greater 28-day readmissions only among frail patients (P = 0.028). Multivariable regression demonstrated that timely GOC was associated only with in-hospital mortality in both frail and non-frail patients, independent of age and gender. CONCLUSION Older frail hospitalised patients were more likely to have timely GOC than older non-frail patients. Timely GOC in such patients may avoid burdensome treatments.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, The Bays Hospital, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Department of Intensive Care, Peninsula Private Hospital, Victoria, Australia
| | - Cameron Green
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Velandai Srikanth
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Department of Geriatric Medicine, Peninsula Health, Frankston, Victoria, Australia
- Menzies Institute for Medical Research, Hobart, Tasmania, Australia
| | - Lionel Soh
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, Monash Health, Clayton, Victoria, Australia
| | - Aun Chian Yeoh
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, Monash Health, Clayton, Victoria, Australia
| | - Faisal Hussain
- Business Intelligence Unit, Peninsula Health, Frankston, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
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Incorvaia C, Scarpazza P, Riario-Sforza GG. Do not intubate order, is the misunderstanding finally over? Ann Thorac Med 2018; 13:195. [PMID: 30123341 PMCID: PMC6073790 DOI: 10.4103/atm.atm_113_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Paolo Scarpazza
- Division of Broncopneumotisiology, Civile Hospital, Vimercate, Italy
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Huang BY, Chen HP, Wang Y, Deng YT, Yi TW, Jiang Y. The do-not-resuscitate order for terminal cancer patients in mainland China: A retrospective study. Medicine (Baltimore) 2018; 97:e0588. [PMID: 29718859 PMCID: PMC6392573 DOI: 10.1097/md.0000000000010588] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
With the development of palliative care, a signed do-not-resuscitate (DNR) order has become increasingly popular worldwide. However, there is no legal guarantee of a signed DNR order for patients with cancer in mainland China. This study aimed to estimate the status of DNR order signing before patient death in the cancer center of a large tertiary affiliated teaching hospital in western China. Patient demographics and disease-related characteristics were also analyzed.This was a retrospective chart analysis. We screened all charts from a large-scale tertiary teaching hospital in China for patients who died of cancer from January 2010 to February 2015. Analysis included a total of 365 records. The details of DNR order forms, patient demographics, and disease-related characteristics were recorded.The DNR order signing rate was 80%. Only 2 patients signed the DNR order themselves, while the majority of DNR orders were signed by patients' surrogates. The median time for signing the DNR order was 1 day before the patients' death. Most DNR decisions were made within the last 3 days before death. The time at which DNR orders were signed was related to disease severity and the rate of disease progression.Our findings indicate that signing a DNR order for patients with terminal cancer has become common in mainland China in recent years. Decisions about a DNR order are usually made by patients' surrogates when patients are severely ill. Palliative care in mainland China still needs to be improved.
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Affiliation(s)
- Bo-Yan Huang
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Hui-Ping Chen
- Department of Palliative Medicine, West China Fourth Hospital, Sichuan University
| | - Ying Wang
- Department of Medical Oncology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, People's Republic of China
| | - Yao-Tiao Deng
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Ting-Wu Yi
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Yu Jiang
- Department of Medical Oncology, Cancer Center, West China Hospital
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Arabi YM, Al-Sayyari AA, Al Moamary MS. Shifting paradigm: From "No Code" and "Do-Not-Resuscitate" to "Goals of Care" policies. Ann Thorac Med 2018; 13:67-71. [PMID: 29675055 PMCID: PMC5892090 DOI: 10.4103/atm.atm_393_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Policies addressing limitations of medical therapy in patients with advanced medical conditions are typically referred to as Code Status (No Code) policies or Do-Not-Resuscitate (DNR) status polices. Inconsistencies in implementation, understanding, decision-making, communication and management of No Code or DNR orders have led to delivery of poorer care to some patients. Several experts have called for a change in the current approach. The new approach, Goals of Care paradigm, aims to contextualize the decisions about resuscitation and advanced life support within the overall plan of care, focusing on choices of treatments to be given rather than specifically on treatments not to be given. Adopting “Goals of Care” paradigm is a big step forward on the journey for optimizing the care for patients with advanced medical conditions; a journey that requires collaborative approach and is of high importance for patients, community and healthcare systems.
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Affiliation(s)
- Yaseen M Arabi
- Department of Intensive Care, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdulla A Al-Sayyari
- Division of Nephrology and Renal Transplantation, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mohamed S Al Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Cummings A, Lund S, Campling N, May C, Richardson A, Myall M. Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review. BMJ Open 2017; 7:e017056. [PMID: 28988176 PMCID: PMC5640076 DOI: 10.1136/bmjopen-2017-017056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To identify the factors that promote and inhibit the implementation of interventions that improve communication and decision-making directed at goals of care in the event of acute clinical deterioration. DESIGN AND METHODS A scoping review was undertaken based on the methodological framework of Arksey and O'Malley for conducting this type of review. Searches were carried out in Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) to identify peer-reviewed papers and in Google to identify grey literature. Searches were limited to those published in the English language from 2000 onwards. Inclusion and exclusion criteria were applied, and only papers that had a specific focus on implementation in practice were selected. Data extracted were treated as qualitative and subjected to directed content analysis. A theory-informed coding framework using Normalisation Process Theory (NPT) was applied to characterise and explain implementation processes. RESULTS Searches identified 2619 citations, 43 of which met the inclusion criteria. Analysis generated six themes fundamental to successful implementation of goals of care interventions: (1) input into development; (2) key clinical proponents; (3) training and education; (4) intervention workability and functionality; (5) setting and context; and (6) perceived value and appraisal. CONCLUSIONS A broad and diverse literature focusing on implementation of goals of care interventions was identified. Our review recognised these interventions as both complex and contentious in nature, making their incorporation into routine clinical practice dependent on a number of factors. Implementing such interventions presents challenges at individual, organisational and systems levels, which make them difficult to introduce and embed. We have identified a series of factors that influence successful implementation and our analysis has distilled key learning points, conceptualised as a set of propositions, we consider relevant to implementing other complex and contentious interventions.
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Affiliation(s)
- Amanda Cummings
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Susi Lund
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Natasha Campling
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Carl May
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
- University Hospital Southampton, NHS Foundation Trust, Southampton, UK
| | - Alison Richardson
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
- University Hospital Southampton, NHS Foundation Trust, Southampton, UK
| | - Michelle Myall
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
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Frenette M, Saint-Arnaud J, Serri K. Levels of Intervention: How Are They Used in Quebec Hospitals? JOURNAL OF BIOETHICAL INQUIRY 2017; 14:229-239. [PMID: 28324205 DOI: 10.1007/s11673-017-9778-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 10/21/2016] [Indexed: 06/06/2023]
Abstract
In order to promote better practices and communication around end-of-life decision-making, several Canadian hospitals in the province of Quebec have developed a tool called "Levels of Intervention" (LOI). No work to date has been published demonstrating improvement since these forms were implemented. The purpose of the present study was to obtain information about the use of LOI forms across Quebec hospitals and to identify gaps in practice as well as areas for improvement. A retrospective study was undertaken of 299 charts of patients who had died in three Quebec hospitals with a LOI ordered. Results were analysed through a principlism ethical framework. High compliance with the level of intervention ordered at the time of death was recorded, as well as high involvement of patient and/or family, demonstrating the efficiency of LOI in promoting respect for autonomy. Other results show delays in end-of-life care discussions in the course of the hospitalization. Only a small proportion of patients who died had a palliative care consultation, which may reflect equity issues in access to care. This study highlights the importance of the LOI in Quebec and the role it is playing in respect for end-of-life preferences as well as in the involvement of patients and families in the decision-making process. Training specific to end-of-life decision-making conversations would help support the LOI form's use, as would developing provincial or national guidelines on the use of LOI to standardize organizational policies and practice around end-of-life care.
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Affiliation(s)
- Marjolaine Frenette
- Public Health School (local 3035), University of Montreal, C. P. 6128, succ. Centre-ville, Montréal, Québec, H3C 3J7, Canada.
| | - Jocelyne Saint-Arnaud
- Department of Social and Preventive Medicine, Public Health School, University of Montreal and Center for Research in Ethics (CRÉ), President Clinical Ethics Committee, Sacré-Coeur Hospital, Montreal, QC, Canada
| | - Karim Serri
- Sacré-Coeur Hospital and University of Montreal, Montreal, QC, Canada
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Zafar W, Ghafoor I, Jamshed A, Gul S, Hafeez H. Outcomes of In-Hospital Cardiopulmonary Resuscitation Among Patients With Cancer. Am J Hosp Palliat Care 2016; 34:212-216. [PMID: 26589879 DOI: 10.1177/1049909115617934] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review all episodes where an emergency code was called in a cancer-specialized hospital in Pakistan and to assess survival to discharge among patients who received a cardiopulmonary resuscitation (CPR). METHODS We reviewed demographic and clinical data related to all "code blue" calls over 3 years. Multivariate logistic regression analyses were used to test the association of clinical characteristics with the primary outcome of survival to discharge. RESULTS A total of 646 code blue calls were included in the analysis. The CPR was performed in 388 (60%) of these calls. For every 20 episodes of CPR among patients with cancer of all ages, only 1 resulted in a patient's survival to discharge, even though in 52.2% episodes there was a return of spontaneous circulation. No association was found between the type of rhythm at initiation of CPR and likelihood of survival to discharge. CONCLUSIONS The proportion of patients with advanced cancer surviving to discharge after in-hospital CPR in a low-income country was in line with the reported international experience. Most patients with cancer who received in-hospital CPR did not survive to discharge and did not appear to benefit from resuscitation. Advance directives by patients with cancer limiting aggressive interventions at end of life and proper documentation of these directives will help in provision of care that is humane and consonant with patients' wishes for a dignified death. Patients' early appreciation of the limited benefits of CPR in advanced cancer is likely to help them formulate such advance directives.
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Affiliation(s)
- Waleed Zafar
- 1 Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Irum Ghafoor
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Arif Jamshed
- 3 Department of Radiation Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Sabika Gul
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Haroon Hafeez
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
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Aziz H, Branco BC, Braun J, Hughes JD, Goshima KR, Trinidad-Hernandez M, Hunter G, Mills JL. The influence of do-not-resuscitate status on the outcomes of patients undergoing emergency vascular operations. J Vasc Surg 2015; 61:1538-42. [PMID: 25704406 DOI: 10.1016/j.jvs.2014.11.087] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/18/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Do-not-resuscitate (DNR) orders allow patients to communicate their wishes regarding cardiopulmonary resuscitation. Although DNR status may influence physician decision making regarding resuscitation, the effect of DNR status on outcomes of patients undergoing emergency vascular operation remains unknown. The aim of this study was to analyze the effect of DNR status on the outcomes of emergency vascular surgery. METHODS The National Surgical Quality Improvement Program database was queried to identify all patients requiring emergency vascular surgical interventions between 2005 and 2010. Demographics, clinical data, and outcomes were extracted. Patients were compared according to DNR status. The primary outcome measure was 30-day mortality. RESULTS During the study period, 16,678 patients underwent emergency vascular operations (10.8% of the total vascular surgery population). Of those, 548 patients (3.3%) had a DNR status. The differences in rates of open or endovascular repair or of intraoperative blood requirement between the two groups were not significant. After adjusting for differences in demographics and clinical data, DNR patients were more likely to have higher rates of graft failure (8.7% vs 2.4%; adjusted P < .01) and failure to wean from mechanical ventilation (14.9 % vs 9.9%; adjusted P < .001). DNR status was associated with a 2.5-fold rise in 30-day mortality (35.0% vs 14.0%; 95% confidence interval, 1.7-2.9; adjusted P < .001). CONCLUSIONS The presence of a DNR order was independently associated with mortality. Patient and family counseling on surgical expectations before emergency vascular operations is warranted because the risks of perioperative events are significantly elevated when a DNR order exists.
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Affiliation(s)
- Hassan Aziz
- Department of Surgery, University of Arizona, Tucson, Ariz.
| | | | - Jonathan Braun
- Division of Vascular and Endovascular Surgery, University of Arizona Medical Center, Tucson, Ariz
| | - John D Hughes
- Division of Vascular and Endovascular Surgery, University of Arizona Medical Center, Tucson, Ariz
| | - Kay R Goshima
- Division of Vascular and Endovascular Surgery, University of Arizona Medical Center, Tucson, Ariz
| | | | - Glenn Hunter
- Division of Vascular Surgery, Southern Arizona Veteran Affairs Health Care System, Tucson, Ariz
| | - Joseph L Mills
- Division of Vascular and Endovascular Surgery, University of Arizona Medical Center, Tucson, Ariz
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Scarborough JE, Pappas TN. The effect of do-not-resuscitate status on postoperative mortality in the elderly following emergency surgery. Adv Surg 2013; 47:213-225. [PMID: 24298853 DOI: 10.1016/j.yasu.2013.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Elderly patients who have preexisting DNR orders experience a high incidence of mortality and major morbidity within 30 days after emergency general surgery. Although not a risk factor for major morbidity, preoperative DNR status does represent an independent risk factor for mortality after emergency general surgery. The most plausible reason for the excess mortality in DNR patients is their decreased willingness to undergo aggressive treatment of major postoperative complications. Whether patient-driven failure-to-pursue-rescue also explains to some extent the high mortality of non-DNR elderly emergency general surgery patients deserves further investigation.
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Affiliation(s)
- John E Scarborough
- Department of Surgery, Duke University School of Medicine, DUMC 2837, Durham, NC 27710, USA.
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Abstract
Quality standards no longer allow physicians to delay discussing goals of care and resuscitation. We propose 2 novel strategies for discussing goals and resuscitation on admission. The first, SPAM (determine Surrogate decision maker, determine resuscitation Preferences, Assume full care, and advise them to expect More discussion especially with clinical changes), helps clinicians discover patient preferences and decision maker during routine admissions. The second, UFO-UFO (Understand what they know, Fill in knowledge gaps, ask about desired Outcomes, Understand their reasoning, discuss the spectrum Feasible Outcomes), helps patients with poor or uncertain prognosis or family–team conflict. Using a challenging case example, this article illustrates how SPAM and UFO-UFO can help clinicians have patient-centered resuscitation and goals of care discussions at the beginning of care.
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Affiliation(s)
- Jocelyn White
- Palliative and Hospice Care, Legacy Medical Group, Legacy Health System, Portland, OR, USA
| | - Erik K. Fromme
- Division of Hematology and Medical Oncology, OHSU Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
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12
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Gehlbach TG, Shinkunas LA, Forman-Hoffman VL, Thomas KW, Schmidt GA, Kaldjian LC. Code status orders and goals of care in the medical ICU. Chest 2011; 139:802-809. [PMID: 21292755 PMCID: PMC3198491 DOI: 10.1378/chest.10-1798] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 12/02/2010] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care. METHODS We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders. RESULTS Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents' average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status (P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care. CONCLUSIONS Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients' code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.
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Affiliation(s)
- Thomas G Gehlbach
- Division of Pulmonary and Critical Care Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Laura A Shinkunas
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Valerie L Forman-Hoffman
- Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Karl W Thomas
- Division of Pulmonary and Critical Care Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Gregory A Schmidt
- Division of Pulmonary and Critical Care Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Lauris C Kaldjian
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, IA; Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.
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