Timing of code status documentation and end-of-life outcomes in patients admitted to an oncology ward

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<ul><li><p>ORIGINAL ARTICLE</p><p>Timing of code status documentation and end-of-life outcomesin patients admitted to an oncology ward</p><p>Amanda Caissie &amp; Nanor Kevork &amp; Breffni Hannon &amp;Lisa W. Le &amp; Camilla Zimmermann</p><p>Received: 4 June 2013 /Accepted: 11 September 2013 /Published online: 28 September 2013# Springer-Verlag Berlin Heidelberg 2013</p><p>AbstractPurpose Guidelines recommend documentation of care pref-erences for patients with advanced cancer upon hospital ad-mission. We assessed end-of-life outcomes for patients whodid or did not have code status (CS) documented within 48 hof admission.Methods This was a retrospective cohort study of patientswho died on an inpatient oncology ward between January2004 and February 2009. Primary end-of-life outcomes werecode blues and cardiopulmonary resuscitation (CPR) at-tempts; secondary outcomes included unsuccessful CPR at-tempts, intensive care unit (ICU), consultations, and ICUadmissions. Using logistic regression, outcomes were com-pared between those with and without CS documentation48 h from admission (full code or do-not-resuscitate), con-trolling for significant confounders.</p><p>Results The 336 patients had a median age of 61 years; 97 %had advanced cancer. The median time from admission todeath was 12 days (range </p></li><li><p>The success rate of CPR is even lower in patients withcancer, and is further reduced by metastatic disease, poorperformance status, advanced age, and acute illnesses includ-ing infection [6, 8, 9]. A meta-analysis of 42 studies from1966 to 2005, specifically in hospitalized patients with cancer,reported an overall survival rate to discharge of 6.2 % (9.5 %in patients with localized disease and 5.6 % in patients withmetastatic disease) [9]. For patients whose cardiac arrest wasanticipated, rather than occurring unexpectedly, the survivalrate to discharge after CPR was 0 % [8].</p><p>Due to these exceedingly low rates of success for CPR inhospitalized patients with cancer, guidelines recommend thatfor patients with advanced cancer, goals of care should bereviewed and documented within 48 h of any admission to ahospital [10]. While the latter publication does not explicitlydefine advanced cancer, it has been defined elsewhere ascancer that is incurable [11]. These recommendations forgoals of care discussions are in line with the Patient SelfDetermination Act, which requires that all institutions in theUSA that are receiving Medicare/Medicaid funds inform pa-tients, upon admission, of their right to accept or refusetreatment and their right to an advance directive, regardlessof whether or not their cancer is in the advanced stages [12].However, the guideline of documenting goals of care within48 h is founded only from level III evidence (textbooks,opinions, and descriptive studies) [10]. Scant evidence existsregarding both the frequency with which code status is actu-ally documented within 48 h of admission, and whether thisserves to reduce aggressive end-of-life care [13].</p><p>Early code status documentation may decrease the numberof patients subjected to aggressive interventions not appropri-ately aligned with goals of care. The aims of the current studywere (1) to assess the timing of code status documentation in allpatients who died after admission to an oncology ward and (2)to examine whether code status documentation within 48 h wasassociated with less aggressive end-of-life care. We hypothe-sized that code status documentation within 48 h would beassociated with fewer code blues and CPR attempts. Second-ary outcomes included unsuccessful CPR attempts and inten-sive care unit (ICU) consultations and admissions before death.</p><p>Materials and methods</p><p>Study site and sample</p><p>The study took place at Princess Margaret Hospital (PMH), acomprehensive cancer center and member of the UniversityHealth Network (UHN) in Toronto, Canada. In addition toPMH, the UHN also includes two general hospitals: TorontoGeneral Hospital and Toronto Western Hospital. The studysample included consecutive inpatients that died between Janu-ary 2004 and February 2009, inclusive, on the two general</p><p>oncology (medical or radiation oncology) wards at PMH, whichhave a total of 40 beds. Patients admitted to these wards all havesolid tumors, with the exception of a small minority of patientswith lymphoma or multiple myeloma who are admitted forpalliative radiation. PMH also has 69 beds allocated for patientswith hematologic malignancies and a 12-bed palliative care unit(PCU); patients who died on these units were not included in thestudy. PMH has no emergency department; however, patientshave access to the emergency departments of the other UHNhospitals. Patients may be admitted either directly from ambula-tory care; transferred from general medical or surgical wards atanother hospital; or transferred after presenting at the emergencydepartment at another hospital.While PMH has no ICU, patientshave access to ICU care at the adjacentMount Sinai Hospital viaa bridge connecting the two hospitals.</p><p>This research was conducted following approval of theUHN Research Ethics Board. Two investigators (AC andNK) conducted a thorough retrospective chart review, using astandardized abstraction spreadsheet. Data abstracted includedinformation on patient demographics, cancer diagnosis andstage, admission date, reason for admission, admitting service,status of the physician admitting the patient (patients may beadmitted onto the service of a staff physician by this physicianpersonally or by a hospitalist, fellow, or resident), code statusdocumentation, ICU consultations and admissions, CPR at-tempts (and outcome thereof), and date and cause of death.</p><p>Data collection was facilitated by the availability of data-bases and standardized forms. The reason for admission isspecified by the admitting physician at the time that the patientis placed on the waiting list for admission, and is then enteredinto the standardized database by the admissions coordinator(a registered nurse) using a drop-down menu of differentpotential reasons for admission. When there are multiplereasons for admission, the primary reason is recorded. For thisstudy, the 28 reasons for admission listed in the database weregrouped into three categories: symptom control, cancer treat-ment or investigation, and palliative planning (Table 1). Thelast category was taken unaltered from the database, and refersto patients whose condition is deteriorating at home, and whoare admitted with the anticipation of transfer to hospice orPCU or discharge home with further support.</p><p>Code status documentation and ICU consultations andadmissions were abstracted from the physicians orders andfrom the chart notes. Code status documentation was takenfrom the inpatient medical orders, because according to UHNpolicy, this is where DNR documentation must be, to befollowed for inpatients. Code status was classified as fullcode or DNR. A DNR order precludes the interventionsof chest compressions, defibrillation, or intubation in the eventof a cardiopulmonary arrest, but does not preclude an ICUconsultation or admission. Details of code blues and CPRattempts and outcomes were abstracted from standardizedforms completed by the code blue team. The date and cause</p><p>376 Support Care Cancer (2014) 22:375381</p></li><li><p>of death was obtained from the death certificate, a copy ofwhich was included in each chart.</p><p>A code blue was defined as any medical emergencywhere there was documented involvement of the code blueteam (cardiopulmonary arrest or near-cardiopulmonary ar-rest). CPR attempts were defined as instances where therewere documented attempts at resuscitation, including chestcompressions, defibrillation, and/or intubation. CPR was de-fined as successful if the patient was revived and survivedfor one or more days and unsuccessful if the patient was notrevived or survived for less than 1 day. All ICU admissions atPMH are preceded by an ICU consultation, but an ICUconsultation does not necessarily result in an admission tothe ICU. All code blues result in an ICU consultation; inaddition, the ICU staff may provide consultations on thePMH oncology wards for medical emergencies that have notyet progressed to the severity of a code blue. ICU consulta-tions may also be requested pre-emptively, to provide inputregarding whether or not CPR and ICU admission would beappropriate for a particular patient. These pre-emptive consul-tations are rare and supplement rather than replace the moreusual situation of a code status discussion with the primaryoncologist, admitting oncology team, or palliative care team.</p><p>A UHN policy is in place to guide the medical team throughdecision making with respect to life support interventions andcode status discussions. During the study period, there was noinstitutional policy or guideline regarding the actual timing ofsuch code status discussions, nor is there one currently.</p><p>Statistical analysis</p><p>Associations between timing of initial code status documen-tation (48 h from admission, vs. longer or not at all) andpatient characteristics were assessed using chi-square, Fishersexact, and t tests, as appropriate. Associations between timing</p><p>of code status documentation and end-of-life outcomes (codeblue, CPR attempt, unsuccessful CPR attempt, ICU consulta-tion, ICU admission) were then assessed using multivariablelogistic regression analyses, adjusting for significant con-founders. Confounders were defined as patient characteristicsassociated with both timing of code status documentation andany end-of-life outcome (p </p></li><li><p>code) was transferred to the ICU after a code blue and success-ful CPR. Of the five who did not have code status documented,all had unsuccessful CPR after a code blue. All of these patientshad advanced illness and deteriorating status on admission.</p><p>The demographics of all 336 patients are presented in Table 3,both for the entire study population and according to timing ofcode status documentation. Of all patients, (295/336) had stageIV disease on admission; of those with non-stage IV disease, allbut 10 (3 % of the whole sample) had advanced, incurabledisease at admission (for example advanced glioblastoma).Ninety-six percent died of their cancer, with the remaining 13patients dying either from complications of the disease or fromsevere medical comorbidities. Code status documentation 48 hafter admission was associated with being married and admis-sion for palliative planning and negatively associated with ad-mission for cancer treatment or investigation. Specifically, 29/34(85 %) of patients admitted for palliative planning, 87/195(45 %) admitted for symptom control, and 35/107 (33 %) ofpatients admitted for cancer treatment or investigation, had codestatus documentation within 48 h.</p><p>After excluding the 34 patients who were admitted forpalliative planning, and adjusting for other reason for admis-sion and marital status, patients with code status documenta-tion 48 h from admission had significantly fewer codeblues, CPR attempts, and ICU consultations and admis-sions (Table 4). All 20 CPR attempts in the group that did nothave code status documented within 48 h after admission wereunsuccessful (for 18 attempts the patient was not revived; for2, the patient survived less than 24 h), whereas the 2 in the 48group (both full code documentations) were successful inreviving the patient. In both of these cases with successfulCPR attempts, the patients code status was changed to DNRupon transfer back to the oncology ward (3 to 11 days post-CPR), and cancer-related death occurred within 3 weeks ofinitial resuscitation.</p><p>We repeated the analyses discounting the patients who diedwithin 48 h of admission, and the results remained significantfor all outcomes (p </p></li><li><p>Table 3 Patient characteristics according to timing of code status</p><p>Characteristic All patients (n =336) Code status documented within 48 h of admission Univariable</p><p>Numbers (%) Yes (n =151) No (n =185) OR (95 % CI) p Value</p><p>Age (years)</p><p>median (range) 61 (2394) 63 (2387) 61 (2794) 1.00 (0.98-1.01) 0.71</p><p>Sex</p><p>Female 186 (55) 81 (54) 105 (57) 0.88 (0.571.36) 0.57</p><p>Male 150 (45) 70 (46) 80 (43) </p><p>Marital status</p><p>Married/common law 229 (69) 112 (76) 117 (64) 1.76 (1.082.84) 0.02</p><p>Not marrieda 102 (31) 36 (24) 66 (36) </p><p>Unknown 5 3 2 </p><p>Interpreter needed</p><p>Yes 37 (11) 20 (87) 17 (9) 1.51 (0.763.00) 0.24</p><p>No 299 (89) 131 (13) 168 (91) </p><p>Religious affiliation</p><p>Yes 136 (41) 65 (43) 71 (38) 1.21 (0.781.88) 0.39</p><p>No 200 (59) 86 (57) 114 (62) </p><p>Primary cancer site 0.16</p><p>Gastrointestinal 74 (22) 32 (21) 42 (23) 1.27 (0.622.58)</p><p>Lung 64 (19) 37 (25) 27 (15) 2.28 (1.104.76)</p><p>Gynecological 55 (16) 22 (15) 33 (18) 14.11 (0.522.39)</p><p>Breast 30 (9) 13 (9) 17 (9) 1.28 (0.523.14)</p><p>Genitourinary 30 (9) 17 (11) 13 (7) 2.18 (0.885.37)</p><p>Head and neck 27 (8) 9 (6) 18 (10) 0.83 (0.322.19)</p><p>Other 56 (17) 21 (14) 35 (19) </p><p>Stage at admission</p><p>Stage IV 295 (88) 134 (89) 161 (87) 1.18 (0.612.28) 0.63</p><p>Other 41 (12) 17 (11) 24 (13) </p><p>Cause of death</p><p>Cancer 323 (96) 147 (97) 176 (95) 1.88 (0.576.23) 0.30</p><p>Other 13 (4) 4(3) 9 (5) </p><p>Admitting service</p><p>Medical oncology 249 (74) 119 (79) 130 (70) 1.57 (0.952.60) 0.08</p><p>Radiation oncology 87 (26) 32 (21) 55 (30) </p><p>Admitting physician</p><p>Staff/hospitalist 155 (46) 68 (45) 87 (47) 0.92 (0.601.42) 0.72</p><p>Otherb 181 (54) 83 (55) 98 (53) </p><p>Reason for admission 1 year 103 (31) 53 (35) 50 (27) 1.54 (0.882.69)</p><p>&gt;1 month to 1 year 135 (40) 58 (38) 77 (42) 1.09 (0.641.85)1 month 98 (29) 40 (26) 58 (31) </p><p>a Not married includes single, separated, divorced or widowedbOther includes fellows, residents and unknown</p><p>Support Care Cancer (2014) 22:375381 379</p></li><li><p>with the primary oncologist prior to admission as a part ofadvance care planning, in which case, the status just needsto be reverified and documented on admission to a hospital.</p><p>Patients and family members may be reassured byknowing that a DNR status does not preclude otheractive treatments directed either at the cancer itself or atcomplications such as infections [30]. As well, not all codestatus discussions necessarily result in a DNR order. Interest-ingly, in the current study, all those patients who initiallyhad full code status documentation (whether before orafter 48 h from admission) either had successful codes(n =2), or had their code status subsequently changed toDNR before a code blue was called (n =10). This mayindicate that early code status discussions resulting in fullcode orders may also allow patients and substitute-decisionmakers the time to consider less aggressive end-of life careand reconsider DNR orders.</p><p>In the present study, only 33 % of those admitted forcancer treatment or investigation had documentation ofcode status within 48 h. However, the large majority ofthe latter group of patients had incurable disease, and thetreatments offered were thus of palliative intent. Patientsundergoing such treatments may have misconceptions re-garding the purpose of palliative treatment or of the poorprognosis associated with their disease [31]. Of note, therewas an increased rate of DNR discussions 48 h fromadmission in patients with a sp...</p></li></ul>


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