When it comes to discussing a patient’s wishes for code status care, practices at the institution play a more important role than almost any other factor, according to a new study, “Factors Associated with Discussion of Care Plans and Code Status at the Time of Hospital Admission: Results from the Multicenter Hospitalist Study,” in the Journal of Hospital Medicine.
“What was most surprising to me was how variable the discussion rate was,” lead author Andrew Auerbach, MD, tells The Hospitalist. “It had little or nothing to do with how sick the patient was, or with the type of institution in which the discussion took place.”
Hospitalists are no more or less likely to document such discussions than doctors in any other specialty, says Dr. Auerbach, a hospitalist and associate professor of medicine at the University of California San Francisco. He and his colleagues analyzed data from patients admitted to the general medicine services at six academic medical centers as part of the Multicenter Hospitalist Study. Each site complied with requirements established by the Patient Self-Determination Act (PSDA), which says patients must be informed of their right to create an advance directive.
None of the hospitals in the study had established guidelines or formal policies regarding physician-patient discussions about code status or end-of-life care. Patients were interviewed immediately after informed consent was obtained, usually within 24 hours of admission. In each case, the authors determined whether or not the patient had had a care discussion, defined as a documented discussion “between patients (or family) and at least one physician … during the first 24 hours of hospitalization,” the authors write. “Care discussions needed to specify that the person who wrote the note had actually spoken with the patient or their family for the purposes of determining preferences for care, and that this discussion resulted in a specific care plan.”
A notation, such as “the patient continues to want full efforts,” qualified as a care discussion. Less-specific comments, such as “DNR/DNI” or “spoke with family, questions answered,” did not qualify. “These were all really, really sick people, and it was important to assess their wishes for care,” Dr. Auerbach says. Individually, PSDA or durable power of attorney may not adequately convey a patient’s true wishes, because often times the measures involve nothing more than having the patient or family complete a form. “The true marker is a conversation,” he says.
—Andrew Auerbach, MD, University of California San Francisco
By the Numbers
Of 17,097 patients interviewed, only 1,776 (10.4%) had a documented care discussion within 24 hours of hospital admission. The frequency of discussions varied from a low of 2.8% at one institution, to a high of 24.9% at another.
On unadjusted analysis, patients with documented care discussions were more likely to have living wills, durable powers of attorney, or the names of surrogate decision-makers in their charts (P<0.0001 for all categories). These patients were older, more likely to be white, and more likely to be on Medicare, compared to patients without documented care discussions.
The unadjusted analysis also showed patients with care discussions were more likely to be married, but less likely to be living in their own home or apartment, and, not surprisingly, more likely to have been hospitalized at least once within the previous 12 months. Overall, the general health of patients with care discussions was poorer than those without. Patients with documented discussions were more likely to report needing help within the past month with chores or bathing or dressing themselves, than were patients who did not have care discussions. Cancer, depression, and a history of stroke were common among patients with care discussions. Compared to patients without documented discussions, those who did have the discussion appear to want more of a say in their care: they were less likely to agree with the study statements, “I prefer my doctor give me choices regarding my care,” and “I prefer to leave care decisions to my physician.”