Characterizing Physician Recommendations within Code Status Documentation: A Multicentre Cohort Study and Qualitative Discourse Analysis.

Abstract

Background: Discussion of patients' treatment preferences for cardiopulmonary resuscitation is routine practice for adults admitted to hospital. Ideally, these "code status discussions" provide an opportunity to ensure patients receive care that is concordant with their values and priorities. The degree of physician recommendations that occur during these discussions is unknown.

Objective: This study sought to characterize physician treatment recommendations during code status discussions in older hospitalized medical patients.

Design, participants, and approach: We conducted a retrospective cohort study of 200 patients, 75 years or older, admitted to the general medical service in one of four hospitals in Toronto, Canada. Medical records were reviewed to abstract documentation by physicians that referenced a code status discussion. We used qualitative discourse analysis to characterize the nature of these documented code status discussions, with a focus on physician treatment recommendations.

Key results: The majority of recommendations involved de-escalation or avoidance of invasive treatments. The strength of recommendations ranged from a passive physician role of providing advice, where the ultimate decision was deferred to the patient/surrogate, to an active role of explicitly not offering interventions, which involved informed non-dissent. Physicians often documented a brief rationale for specific recommendations, either focused on their estimation that the patient had a poor prognosis or their interpretation of the patient's goals and priorities. However, there was a paucity of documentation supporting how physicians determined these interpretations. Some physicians used the term "quality of life" to imply that invasive life-sustaining treatments were unlikely to benefit the patient.

Conclusions: We uncovered a range of physician practices in providing recommendations during code status discussions. While the strength and rationale varied, physicians often failed to document patients' goals and priorities when making treatment recommendations. These findings highlight an opportunity to improve how physicians formulate, communicate, and document their recommendations around code status.