Journal of Critical Care (2009) 24, 288–292

Documentation of code status and discussion of goals ofcare in gravely ill hospitalized patientsAbigail Holley MDa,⁎, Steven J. Kravet MD, MBAb,1, Grace Cordts MD, MPH, MSc,1

aSection of Geriatrics, Department of Medicine, University of Chicago, Medical Center, Chicago, IL 60637, USAbDivision of General Internal Medicine, Department of Medicine, Johns Hopkins Bayview, Medical Center, Baltimore,MD 21224, USAcDivision of Geriatrics, Department of Medicine, Johns Hopkins Bayview, Medical Center, Baltimore, MD 21224, USA

0d

Keywords:Code status;End of life;Goals of care;Medical education

AbstractBackground: Timely discussions about goals of care in critically ill patients have been shown tobe important.Methods: We conducted a retrospective chart review over 2 years (2003-2004) of patients admitted toour medical service who were classified as “expected to die.” Charts were evaluated for do-not-resuscitate (DNR) documentation and discussions of goals of care. Detailed chart reviews fordemographic information, cause of death, site of death, length of stay, and duration of resuscitationattempt were performed.Results: Of 497 charts identified, 434 (87.3%) had a DNR on file at the time of death. After exclusion ofpatients who died in less than 24 hours, 18 no-DNR charts remained. Seven noted a decision to continueaggressive care and 11 had no code status discussion documented. Younger patients and patients withcardiovascular disease were less likely to have a DNR. Resuscitation times were longer in the no-discussion group. All patients who died without a DNR died in the intensive care unit. Seventy-sixpercent of discussions were done by medicine housestaff.Conclusions: Although the overall rate of DNR documentation was high, several trends emerged.Medicine housestaff in the intensive care unit would be a logical group to target for an educationalintervention to address these discrepancies.© 2009 Elsevier Inc. All rights reserved.

kept alive on life support when there is little hope for a

1. Introduction

Timely discussions about goals of care in critically illpatients have been shown to be important for a variety ofreasons. Patients and their families list one of the mostimportant elements of quality end-of-life care as “not to be

⁎ Corresponding author. Tel.: +1 773 834 5887; fax: +1 773 702 3538.E-mail address: abigail.holley@uchospitals.edu (A. Holley).1 Work completed at Johns Hopkins Bayview Medical Center.

883-9441/$ – see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1016/j.jcrc.2008.03.035

meaningful recovery.” [1] Recognition of goals of care earlyon in a hospitalization may allow for mobilization ofresources, such as a Palliative Care Consulting Team,which is likely to improve symptom management, perceivedquality of life, and perception of in-hospital treatment [2]. Inone study, Ryan et al [3] noted that explicit consultation of aPalliative Care Team regarding goals of care resulted inimprovement not only in discussions of goals of care, butalso in management of symptoms such as pain and nausea.

289Code status in gravely ill patients

From a medical systems perspective, intensive communica-tion has been shown to reduce hospital and intensive careunit (ICU) length of stay as well as duration of use ofultimately nonbeneficial advanced life support measures incritically ill patients [4].

Early research in this area found that without directdialogue between physicians and patients, the physician'sopinion about the patient's attitude toward cardiopulmonaryresuscitation was often incorrect [5]. This emphasizes theneed for open communication between physicians andcritically ill patients. In previous studies, families of ICUpatients have rated physician communication skills to beequally important or more important than clinical skills [6].Unfortunately, studies have revealed that these discussionsoften do not take place or take place only a few days beforedeath [7]. There are many barriers to adequate discussion ofgoals of care [8-10]. However, there is also evidence thateducational interventions may improve communication andquality of discussions between medical housestaff andpatients and their families [11].

The authors evaluated the documentation of do-not-resuscitate (DNR) orders and discussions of goals of care inthe charts of patients who had died while being attended onthe medical service who were classified as “expected to die”during their hospital admissions. Our hope was that patternsidentified might help to shape quality improvement initia-tives, especially in cases of patients who were expected to dieand no discussion took place.

Fig. 1 Flowchart of retrospective chart review.

2. Methods

We conducted a retrospective chart review over 2 years(2003-2004) of patients who died during an admission on ourmedical service and whose deaths were classified as“expected” during admission. Initial identification of expecteddeaths was performed by the hospital's trained qualitymanagement team, and the identification of expected deathssubsequently confirmed by 2 of the authors (AH, SJK). Deathswere identified as expected if (a) the patient was removedfrom life support and/or placed on comfort care measures and/or (b) there was a note from a physician in the chart thatthe patient's death was imminent, the prognosis was grim, orthe patient was not expected to recover. The charts weregrouped by presence or absence of DNR documentation.

A more detailed chart review was done on charts where noDNR order was on file. Information collected included age,sex, cause of death, length of stay, and duration ofresuscitation attempt (if applicable). Cases in which thepatient was admitted to the hospital for less than 24 hoursbefore death were excluded, under the presumption that therewas not time for an adequate discussion of goals of care totake place.

For comparison, we surveyed all “expected death” casesfrom 2004 (aggregated 2003 data were unavailable) and

collected information on demographics, length of stay, causeof death, and site of death. Again, only cases where thepatient had been in the hospital for greater than 24 hourswere evaluated. A total of 18 “no DNR” charts werecompared to 187 “expected death” charts from 2004.

2.1. Statistical analysis

We constructed graphical displays and frequency distribu-tions for patients with and without code status documented.Medians of resuscitation time and hospital length of stay werecalculated for comparison between patients grouped as “noDNR order, no discussion” and “no DNR order, aggressivecare.” P values based on Wilcoxon rank sum test were alsocomputed for the significance of difference between groups.All analyses were carried out using Microsoft Excel andS-plus. After log transformation, the outcomes appear to benormally distributed. We used ordinary linear regression withthese 2 groups as predictors, controlling for age and sex effects.

3. Results

For years 2003 to 2004, 497 charts for expected deathswere identified. Of these 497 expected deaths, 434 (87.3%)had a DNR order on file at the time of death. Of the remaining63 charts, 45 died within the first 24 hours of hospitaladmission and were excluded from chart review. Eighteenpatients were in the hospital for more than 24 hours before anexpected in-hospital death and did not have a DNR on file. In11 cases (61%), there was no discussion documented with thepatient or family about the grim prognosis or code status. In 7cases (39%), a discussion took place with the patient and/ortheir family member or health care agent, and a decision wasmade to continue aggressive care (Fig. 1).

The average age of patients with a DNR on file was 71.7years, whereas the average age of those without a DNR was

Table 1 Do-not-resuscitate documentation by cause ofexpected death (2004)

Cause of death No. with DNR on file (%)

MI/CV disease 29/35 (82.9%)Infection 48/55 (87.3%)Malignancy 18/20 (90%)Pulmonary disease 49/50 (98%)All others 25/27 (92.6%)

MI, myocardial infarction; CV, cardiovascular.

290 A. Holley et al.

64.1 years. There was a slightly higher percentage of malesin the no-DNR-order group (61.1% vs 45.9%). Thedifference between groups for age and sex was notstatistically significant. Of the patients who died ofmyocardial infarction or other cardiovascular disease,82.9% had a DNR on file at the time of death compared to90% of patients with malignancy and 98% of patients withpulmonary disease (Table 1). The median length of stay was9 days in the DNR-order group and the no-discussion group,and 4 days in the aggressive-care group (P = .14). All 18patients without a DNR on file ultimately underwentcardiopulmonary resuscitation before death. Median dura-tion of resuscitation attempt was 33 minutes in the no-discussion group and 13 minutes in the aggressive-caregroup (P = .035) (Table 2). Of all expected deaths for 2004,67.5% occurred in the ICU, but 100% who did not have aDNR on file died in the ICU (P = .004). Seventy-six percentof code status discussions were done by medicine housestaff.

Table 2 Length of stay and resuscitation time in no-DNRgroups

No discussion Aggressivecare

95% CI P

Median LOS(d)

9 4 −0.4118 to1.0954

.14

Medianresuscitationtime (min)

33 13 0.0924 to0.8008

.035

LOS indicates length of stay.

4. Discussion

Establishing goals of care is an important component ofpatient autonomy. It was encouraging to see that the overallrate of DNR discussions was high in our population.However, in a patient-centered system, all patients, espe-cially those that are critically ill, have a right to a discussionabout goals of care. The number of patients with DNR orderson file before in-hospital deaths was similar to data fromother studies [7]. A direct comparison cannot be made to theSUPPORT (The Study to Understand Prognoses andPreferences for Outcomes and Risks of Treatment) trial, asthat study did not explicitly differentiate between expectedand unexpected deaths. It is disappointing to note, however,that little improvement was made in the 15-year periodbetween the initiation of their study and ours, despite therapid emergence of academic palliative care programs duringthe 1990s [12].

There was a trend toward older patients being more likelyto have a DNR on file than younger patients, a finding notparticularly surprising. The differences in age and sexbetween the 2 groups, however, were not statisticallysignificant. Other studies have previously described dis-crepancies in rates of code status discussions based on cause

of death [11]. We had similar findings in that patients whodied of malignancy-related illnesses and pulmonary diseasewere more likely to have a DNR on file at the time of deaththan those who died of cardiovascular disease. A targetedintervention would raise awareness of the need to initiatecode status conversations with younger patients as well asthose with cardiovascular disease.

It is likely that hospitals and patients would benefit inother ways from early and consistent code status discussionsas well. The no-discussion group had longer periods ofultimately futile resuscitation attempts, even when comparedto those patients who desired full code status. This mayreflect the lack of establishment of a clear plan of care forthese very ill patients and/or lack of confidence on the part ofthe medical team as to how best to treat these patients in thecontext of their coexisting illnesses.

The length of stay was equivalent in the group withDNR on file and the no-discussion group (median, 9 daysfor both), and shortest in the aggressive care group(median, 4 days). One possible interpretation of this isthat although lack of discussion may not necessarilyincrease length of stay, overly aggressive intervention inthese critically ill patients may have actually hastened theirdeaths. Another possibility is that although average lengthof stay may not have been changed by the presence of aDNR order, the number of very long (N30 days) ICU staysmay be decreased in patients with code status documenta-tion as shown in previous work [13]. It is important to notethat all of the patients without a DNR on file died in theICU, making the ICU a target for further emphasis ongoals of care discussions. A high-quality discussion ofcode status should involve educating the patient and theirloved ones about what full code or no code means relativeto their overall medical condition [14].

Many barriers to initiation of these discussions have beenoutlined in the past including physician discomfort, fear ofharming the patient-provider relationship, challenging familydynamics, and the time-consuming nature of these conversa-tions when done appropriately [15]. Uncontrolled symptomsin gravely ill patients can also interfere with initiating thesediscussions [3]. A number of these barriers have beenaddressed in recent years with the addition of palliative careconsultation teams to many hospitals, including activepalliation of pain and other symptoms to allow patients to

291Code status in gravely ill patients

participate in these discussions. Proactive identification ofcritically ill patients and subsequent palliative care consulta-tion can lead to earlier identification of prognosis andestablishment of end-of-life treatment goals, reduced ICUlength of stay, and reduced cost of care [16,17]. This firstrequires identification, however, on the part of the ICU team,of patients who may benefit from palliative services.

The ability to communicate with families and establishgoals of care is certainly not limited to physicians withexpertise in palliative care. Studies of ICU care that haveinvolved explicit communication interventions between ICUcaregivers, patients, and their families have also shown theability to decrease length of stay, increase patient and familysatisfaction, and decrease anxiety and depression [4,18,19].Although this may seem a daunting task at first, if done in athoughtful and consistent manner, we would hope thatproviders would increase their level of comfort in talkingabout code status and improve upon their relationships withpatients and their families.

There were a number of limitations to our study. A largenumber of patients did have DNR documentation on file atthe time of their death, leaving a relatively small number ofcharts without code status for review. In addition, theclassification of expected deaths was based on local criteria,which may not readily translate to other institutions. Weevaluated only charts from the medical service of ourhospital and thus cannot comment on how well otherservices, such as surgery or neurology, document goals ofcare. We also chose to exclude charts of patients without aDNR on file who were admitted for less than 24 hours.Although we did not analyze that data specifically, it is likelythat most, if not all, of the 45 patients who died within24 hours without a DNR order had attempts at resuscitation,as the default in our society for gravely ill patients in theabsence of specific code status directives is towardaggressive care. It is important to acknowledge that allpatients who present critically ill, and are expected to die,should ideally have discussions on goals of care. We felt thatin these cases, the patients may not have been able to expresstheir wishes verbally or through an advanced directive, andthere may not have been family immediately available. Wefeel it is important to attempt discussions in all patients butchose to present data that allowed for the most idealopportunity for discussions. Thus, our conclusions may beunderstated. Finally, our setting was a large, academichospital with “teaching” attending physicians overseeingpatient care. Documentation of code status and goals of caremay be different in the case of private attendings overseeingtheir own inpatients.

Despite these limitations, a number of trends came to lightthat may help to shape future practice, behaviors, andtraining of housestaff in academic centers. Medicine house-staff, because of their high level of face-to-face contact withpatients and their families, are a logical group to target for aneducational intervention. Given that all of the patients in ourstudy who died without a DNR on file were admitted to the

ICU, explicit teaching regarding addressing goals of careduring rotations in the ICU would seem to be warranted. Infact, we have recently incorporated such a core componentinto the orientation to our medical ICU rotation. In addition,the data from this study were collected just before theestablishment of a palliative care consultation team at ourinstitution. Giving housestaff the opportunity to rotate withthe palliative care team may also provide them with anopportunity to develop these important skills.

The Accreditation Council for Graduate Medical Educa-tion has identified 6 core competencies: communication,professionalism, systems-based practice, practice-basedlearning and improvement, knowledge, and patient care[20]. Departments of medicine have been noted to success-fully teach about morbidity and mortality in the context ofthe core competencies [21]. Improving the practice of end-of-life discussions meets elements of communication andprofessionalism. Patient care can be improved through lessunnecessary morbidity associated with prolonged resuscita-tion attempts. With the recent initiation of inpatient palliativecare services at many hospitals, the possibility exists to raiseawareness of a systems approach. Lastly, reflecting on (as ifin a mirror) [22] and incorporating this knowledge couldresult in improved practice for housestaff and all members ofthe team.

In summary, we hope that by providing evidence of theopportunity to continue to improve end of life discussions,we can better meet the needs of gravely ill patients andtheir families.

Acknowledgments

The authors are indebted to QiLu Yu, PhD, for herstatistical assistance. Dr Kravet is a Miller-Coulson FamilyScholar through the Johns Hopkins Center for InnovativeMedicine.

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