Social Determinants of Health and Limitation of Life-Sustaining Therapy in Neurocritical Care: A CHoRUS Pilot Project.

BACKGROUND: Social determinants of health (SDOH) have been linked to neurocritical care outcomes. We sought to examine the extent to which SDOH explain differences in decisions regarding life-sustaining therapy, a key outcome determinant. We specifically investigated the association of a patient's home geography, individual-level SDOH, and neighborhood-level SDOH with subsequent early limitation of life-sustaining therapy (eLLST) and early withdrawal of life-sustaining therapy (eWLST), adjusting for admission severity. METHODS: We developed unique methods within the Bridge to Artificial Intelligence for Clinical Care (Bridge2AI for Clinical Care) Collaborative Hospital Repository Uniting Standards for Equitable Artificial Intelligence (CHoRUS) program to extract individual-level SDOH from electronic health records and neighborhood-level SDOH from privacy-preserving geomapping. We piloted these methods to a 7 years retrospective cohort of consecutive neuroscience intensive care unit admissions (2016-2022) at two large academic medical centers within an eastern Massachusetts health care system, examining associations between home census tract and subsequent occurrence of eLLST and eWLST. We matched contextual neighborhood-level SDOH information to each census tract using public data sets, quantifying Social Vulnerability Index overall scores and subscores. We examined the association of individual-level SDOH and neighborhood-level SDOH with subsequent eLLST and eWLST through geographic, logistic, and machine learning models, adjusting for admission severity using admission Glasgow Coma Scale scores and disorders of consciousness grades. RESULTS: Among 20,660 neuroscience intensive care unit admissions (18,780 unique patients), eLLST and eWLST varied geographically and were independently associated with individual-level SDOH and neighborhood-level SDOH across diagnoses. Individual-level SDOH factors (age, marital status, and race) were strongly associated with eLLST, predicting eLLST more strongly than admission severity. Individual-level SDOH were more strongly predictive of eLLST than neighborhood-level SDOH. CONCLUSIONS: Across diagnoses, eLLST varied by home geography and was predicted by individual-level SDOH and neighborhood-level SDOH more so than by admission severity. Structured shared decision-making tools may therefore represent tools for health equity. Additionally, these findings provide a major warning: prognostic and artificial intelligence models seeking to predict outcomes such as mortality or emergence from disorders of consciousness may be encoded with self-fulfilling biases of geography and demographics.

A Controlled Study in CPR-Survival in Propensity Score Matched Full-Code and Do-Not-Resuscitate ICU Patients.

BACKGROUND: Cardiopulmonary Resuscitation (CPR) causes significant injuries and increased cost among transiently resuscitated patients that do not survive their hospitalizations. Descriptive studies show zero and near-zero percent survival for CPR recipients with high Apache II scores. Despite these factors, no controlled studies exist in CPR to guide patient selection for CPR candidacy. Our objective was therefore to perform a controlled study in CPR to inform recommendations for CPR candidacy. We hypothesize that the protective effects of CPR decrease as illness severity increases, and that Full-Code status provides no survival benefit over Do-Not-Resuscitate (DNR) status for patients with the highest predicted mortality by Apache IV score. METHODS: We performed propensity-score matched survival analyses between Full-Code and DNR patients after stratifying by predicted mortality quartiles using Apache IV scores. Primary outcomes were mortality hazard ratios. Secondary outcomes were Median Survival Differences, ICU LOS, and tracheostomy rates. RESULTS: Among 17,710 propensity-score matched ICU encounters, DNR status was associated with greater mortality in the first through third predicted mortality quartiles. There was no difference in survival outcomes in the fourth quartile (HR 0.99, p = .96). There was a stepwise decrease in the mortality hazard ratio for DNR patients as quartiles increased. CONCLUSION: Full-Code status provides no survival benefit over DNR status in individuals with greater than 75% predicted mortality by Apache IV score. There is a stepwise decrease in survival benefit for Full-Code patients as predicted mortality increases. We propose that it is reasonable to consider a very high predicted mortality by Apache IV score a contraindication to CPR given the lack of survival benefit seen in these patients. Larger studies with similar methods should be performed to reinforce or refute these findings.

Shared decision-making in advance care planning among hospitalized older COVID-19 patients: a multicenter, retrospective cohort study.

BACKGROUND: In the Netherlands, it is customary to discuss directives regarding resuscitation, intubation, and ICU-admission with patients and/or their relatives upon hospital-admission. The outcome of this discussion is documented in a code status. Ideally, these advance care planning (ACP)-related decisions are made by a patient (and/or their relatives) and a professional together in a shared decision-making (SDM) process, to improve patient satisfaction and prevent undesired care. Given the bad outcomes in older COVID-19 patients, it is particularly important to discuss the code status upon admission. This study aims to describe the practice of SDM regarding code status during the COVID-pandemic. Specific aims were to find out to what extend patients took part in this decision-making process and whether all key elements of SDM for a shared decision were documented in medical reports. METHODS: In this retrospective cohort study, we included COVID-19 patients aged 70 years and older, admitted to two large teaching hospitals in the Netherlands, during the first months of the COVID-19 pandemic in 2020. Data about code status and the decision-making process were extracted from electronic healthcare records. RESULTS: Code status was documented for 274 of 275 included patients. Patient participation in the decision-making process was described in 48%. In 19% all key elements of shared decision-making have been described. Key elements of SDM were defined as the presence of a completed code status form, the presence of clinical notes showing that both patient's wishes and values and the opinion of the healthcare professional about the predicted outcome was taken into consideration and clinical notes of a patient-healthcare professional interaction during the admission. CONCLUSION: Our results show that a proper SDM process regarding code status is possible, even in hectic times like the COVID-19-pandemic. However, shared decision-making was not common practice in older patients with COVID-19 regarding code status (an ACP-related decision) in the early phase of the COVID-19 pandemic. Only in 19% of the patients, all key elements of SDM regarding code status were described.

Do-not-resuscitate (DNR) status and major depressive disorder (MDD): Clinical association and hospitalization outcomes.

OBJECTIVES: To understand (1) the association of Major Depressive Disorder (MDD) and do-not-resuscitate (DNR) status among hospitalized patients and (2) the association of MDD and hospitalization outcomes among DNR patients. METHODS: This was a cross-sectional analysis of United States Healthcare Cost and Utilization Project, Nationwide Inpatient Sample data from 2009 to 2013 for patients >18 years. To address the first objective, we used multivariable logistic regression among all hospitalized patients to compute the adjusted odds ratio (aOR) of having DNR status if patients have active MDD of varying severities after controlling for age, sex, race, suicidal ideation, and Elixhauser Comorbidity Index. To address the second objective, we used multivariable regression among patients with DNR status to compute aOR of having hospitalization outcomes such as increased length of stay, higher total charges, leaving against medical advice, and mortality if patients have MDD. RESULTS: Among all hospitalizations, 2.3% had DNR status. There was an inverse association between severity of MDD and having DNR status. Relative to those without MDD, patients with moderate recurrent MDD episode (aOR 0.74 (95% confidence interval (CI): 0.65-0.85) and severe recurrent MDD episode (aOR of 0.42 (95% CI: 0.37-0.48)) were significantly less likely to have DNR status. Among DNR patients, those with all severities of MDD except mild single episode MDD were >40% less likely to die during hospitalization. Among DNR patients, patients with MDD had 0.7 day longer length of stay, and >$4,500 higher total charges. SIGNIFICANCE OF RESULTS: Patients are less likely to have DNR status if they have active MDD. Among patients with DNR status, those with MDD are less likely to die during hospitalization than those without MDD. With current practice, depression is not associated with increased likelihood of death due to foregoing resuscitation prematurely, though the exact mechanisms of these findings need further investigation.

Conditions, possibility and priority for admission into inpatient hospice/palliative care units in Japan: a nationwide survey.

BACKGROUND: Known barriers to admission into inpatient hospice/palliative care units (PCUs) include poor accessibility and stringent conditions for admission. However, the exact criteria are unclear. The aim of this study was to clarify the actual conditions, possibilities and priorities for admission to PCU in Japan. METHODS: We conducted a nationwide, anonymous, self-administered questionnaire survey to the responsible physicians of all 251 PCUs in 2014. RESULTS: Responses were received from 190 institutions (response rate 76%). The most frequent condition for admission was 'either the patient or the family knows the diagnosis' [86%, 95% confidence interval (CI): 80-90]. For the conditions for admission to PCU, 10-40% fewer facilities answered that the patient's consent or understanding was required compared with those that answered the patient or family's consent was sufficient. Seventy-one percent (95% CI: 64-77) of PCUs answered that either the patient or a family member needed to agree to a do-not-resuscitate (DNR) policy. The factors most likely to result in refusal of admission to a PCU varied greatly. Ninety-four percent (95% CI: 90-97) of PCUs answered that patients who had undergone a long waiting time after applying for admission would be given higher priority, and approximately 50% of PCUs answered they gave priority to their outpatients and inpatients. CONCLUSIONS: The findings of this study should be used to modify the system so that appropriate palliative care can be provided to patients who wish to be admitted to PCU.

Predictors to forgo resuscitative effort during Covid-19 critical illness at the height of the pandemic : A retrospective cohort study.

BACKGROUND: Early in the Covid-19 pandemic, there was uncertainty regarding critical illness prognosis and challenges to traditional face-to-face family meetings. Ethnic minority populations have suffered disproportionately worse outcomes during the pandemic, which may in part relate to differences in end-of-life decision-making. AIM: Characterize patterns of and factors associated with decisions to forgo resuscitative efforts, as measured by do-not-resuscitate orders, during critical illness with Covid-19. DESIGN: Retrospective cohort with medical record abstraction. SETTING/PARTICIPANTS: Adult patients diagnosed with SARS-Cov-2 virus via polymerase chain reaction and admitted to the intensive care unit at an academic hospital, which cares for the city's underserved communities, between March 1 and June 7, 2020 who underwent invasive mechanical ventilation for at least 48 hours. RESULTS: In this cohort (n = 155), 45% were black people, and 51% spoke English as their primary language. Median time to first goals-of-care conversation was 3.9 days (IQR 1.9-7.6) after intensive care unit admission. Overall 61/155 patients (39%) transitioned to do-not-resuscitate status, and 50/62 (82%) patients who died had do-not-resuscitate orders. Multivariate analysis shows age and palliative care involvement as the strongest predictors of decision to instate do-not-resuscitate order. There was no association between race, ethnicity, or language and decisions to forego resuscitation. CONCLUSIONS: During this time of crisis and uncertainty with limited resources and strained communication, time to first goals of care conversation was shorter than in pre-pandemic studies, but rates of foregoing resuscitation remained similar, with no differences observed by race, ethnicity, or language. This study suggests that early palliative care involvement and non-traditional communications, including videoconferencing, to facilitate goals of care conversations could have mitigated potential disparities in end-of-life decision making patterns during the pandemic.

'It's not magic': A qualitative analysis of geriatric physicians' explanations of cardio-pulmonary resuscitation in hospital admissions.

BACKGROUND: Discussing patient preferences for cardio-pulmonary resuscitation (CPR) is routine in hospital admission for older people. The way the conversation is conducted plays an important role for patient comprehension and the ethics of decision making. OBJECTIVE: The objective was to examine how CPR is explained in geriatric rehabilitation hospital admission interviews, focussing on circumstances in which physicians explain CPR and the content of these explanations. METHOD: We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR was discussed. Data were analysed in French with thematic and conversation analysis, and the extracts used for publication were translated into English. RESULTS: Mean patient age was 83.7 years; 53.5% were admitted for rehabilitation after surgery or traumatism. CPR was explained in 53.8% of the conversations. Most explanations were brief and concerned the technical procedures, mentioning only rarely potential outcome. With one exception, medical indication and prognosis of CPR did not feature in these explanations. Explanations occurred either before the patient's answer (as part of the question about CPR preferences) or after the patient's answer, generated by patients' indecision, misunderstanding and by the need to clarify answers. DISCUSSION AND CONCLUSIONS: The scarcity and simplicity of CPR explanations highlight a reluctance to have in-depth discussions and reflect the assumption that CPR does not need explaining. Providing patients with accurate information about the outcomes and risks of CPR is incremental for reaching informed decisions and patient-centred care. PATIENT CONTRIBUTION: Patients were involved in the data collection stage of the study.

Do Hispanics prefer to be full code at the end of life? The impact of palliative care consults on clarifying code status preferences and hospice referrals in Spanish-speaking patients.

BACKGROUND: Hispanics often have disparities at the end of life. They are more likely to die full code and less likely to have discussions regarding prognosis and do not resuscitate (DNR)/do not intubate (DNI), despite studies showing Hispanic values comfort over the extension of life. Barriers to patient-centered care include language,socioeconomic status and health literacy. CONTEXT: We evaluated the impact of palliative care (PC) consults on the change of code status and hospice referrals, comparing seriously ill Hispanic and non-Hispanic white patients. METHOD: A retrospective cohort study of all white and Hispanic patients referred to the PC service of a county hospital from 2006 to 2012. We evaluated ethnicity, language, code status at admission and after PC consult, and hospice discharge. Chi-squared tests were used to analyze characteristics among three groups: non-Hispanic white, English-speaking Hispanic, and Spanish-speaking Hispanic patients. RESULTS: Of 925 patients, 511 (55%) were non-Hispanic white, 208 (23%) were English-speaking Hispanic, and 206 (22%) were Spanish-speaking Hispanic patients. On admission, there was no statistically significant difference in code status among the three groups (57%, 64%, and 59% were full code, respectively, p = 0.5). After PC consults, Spanish-speaking Hispanic patients were more likely to change their code status to DNR/DNI when compared with non-Hispanic white and English-speaking Hispanic patients (44% vs. 32% vs. 28%, p = 0.05). Spanish-speaking Hispanic patients were more likely to be discharged to hospice when compared with English-speaking Hispanics and non-Hispanic whites (33%, 29%, and 23%, respectively, p = 0.04). SIGNIFICANCE OF RESULTS: Spanish-speaking Hispanic patients were more likely to change from full code to DNR/DNI compared with non-Hispanic white and English-speaking Hispanic patients, despite similar code status preferences on admission. They were also more likely to be discharged to hospice. PC consults may play an important role in helping patients to align their care with their values and may prevent unwanted aggressive interventions at the end of life.

Betting on CPR: a modern version of Pascal's Wager.

Many patients believe that cardiopulmonary resuscitation (CPR) is more likely to be successful than it really is in clinical practice. Even when working with accurate information, some nevertheless remain resolute in demanding maximal treatment. They maintain that even if survival after cardiac arrest with CPR is extremely low, the fact remains that it is still greater than the probability of survival after cardiac arrest without CPR (ie, zero). Without realising it, this line of reasoning is strikingly similar to Pascal's Wager, a Renaissance-era argument for accepting the proposition for God's existence. But while the original argument is quite logical-if not universally compelling-the modern variant makes several erroneous assumptions. The authors here present a case of a patient who unwittingly appeals to Pascal's Wager to explain his request for maximal treatment, in order to highlight the crucial divergences from the original Wager. In understanding the faulty assumptions inherent in the application of Pascal's Wager to code status decisions-and identifying the underlying motivations which the Wager serves to confirm-providers can better ensure that the true values and preferences of patients are upheld.

Association Between Do Not Resuscitate/Do Not Intubate Orders and Emergency Medicine Residents' Decision Making.

BACKGROUND: Research has shown that do not resuscitate (DNR) and do not intubate (DNI) orders may be construed by physicians to be more restrictive than intended by patients. Previous studies of physicians found that DNR/DNI orders are associated with being less willing to provide invasive care. OBJECTIVES: The purpose of this study was to assess the influence of code status on emergency residents' decision-making regarding offering invasive procedures for those patients with DNR/DNI compared with their full code counterparts. METHODS: We conducted a nationwide survey of emergency medicine residents using an instrument of 4 clinical vignettes involving patients with serious illnesses. Two versions of the survey, survey A and survey B, alternated the DNR/DNI and full code status for the vignettes. Residency leaders were contacted in August 2018 to distribute the survey to their residents. RESULTS: Three hundred and three residents responded from across the country. The code status was strongly associated with decisions to intubate or perform CPR and influenced the willingness to offer other invasive procedures. DNR/DNI status was associated with less frequent willingness to place central venous catheters (88.2% for DNR/DNI vs. 97.2% for full code, p < 0.001), admit patients to the intensive care unit (89.9% vs. 99.0%, p < 0.001), offer dialysis (79.3% vs. 98.0%, p < 0.001), and surgical consultation (78.7% vs. 94.2%, p < 0.001). CONCLUSIONS: In a nationwide survey, emergency medicine residents were less willing to provide invasive procedures for patients with DNR/DNI status, including the placement of central venous catheters, admission to the intensive care unit, and consultation for dialysis and surgery.

Predicting Outcomes of In-Hospital Cardiac Arrest: Retrospective US Validation of the Good Outcome Following Attempted Resuscitation Score.

BACKGROUND: Providers should estimate a patient's chance of surviving an in-hospital cardiac arrest with good neurologic outcome when initially admitting a patient, in order to participate in shared decision making with patients about their code status. OBJECTIVE: To examine the utility of the "Good Outcome Following Attempted Resuscitation (GO-FAR)" score in predicting prognosis after in-hospital cardiac arrest in a US trauma center. DESIGN: Retrospective observational study SETTING: Level 1 trauma and academic hospital in Minneapolis, MN, USA PARTICIPANTS: All cases of pulseless in-hospital cardiac arrest occurring in adults (18 years or older) admitted to the hospital between Jan 2009 and Sept 2018 are included. For patients with more than one arrest, only the first was included in this analysis. MAIN MEASURES: For each patient with verified in-hospital cardiac arrest, we calculated a GO-FAR score based on variables present in the electronic health record at time of admission. Pre-determined outcomes included survival to discharge and survival to discharge with good neurologic outcome. KEY RESULTS: From 2009 to 2018, 403 adults suffered in-hospital cardiac arrest. A majority (65.5%) were male with a mean age of 60.3 years. Overall survival to discharge was 33.0%; survival to discharge with good neurologic outcome was 17.4%. GO-FAR score calculated at the time of admission correlated with survival to discharge with good neurologic outcome (AUC 0.68), which occurred in 5.3% of patients with below average survival likelihood by GO-FAR score, 22.5% with average survival likelihood, and 34.1% with above average survival likelihood. CONCLUSIONS: The GO-FAR score can estimate, at time of admission to the hospital, the probability that a patient will survive to discharge with good neurologic outcome after an in-hospital cardiac arrest. This prognostic information can help providers frame discussions with patients on admission regarding whether to attempt cardiopulmonary resuscitation in the event of cardiac arrest.

Outcomes of in-hospital cardiopulmonary resuscitation for patients with end-stage liver disease.

BACKGROUND AND AIMS: There have been improving survival trends after in-hospital cardiac arrest for the general population, but there is limited information on the outcomes of hospitalized patients with end-stage liver disease (ESLD) who undergo cardiopulmonary resuscitation (CPR). We aimed to examine survival to hospital discharge after receipt of in-hospital CPR in patients with ESLD using a nationally representative sample. METHODS: We used the Nationwide Inpatient Sample database from 2006 to 2014 to identify adult patients who underwent in-hospital CPR. Using multivariate modelling, we compared survival to hospital discharge for patients with ESLD to those without ESLD. We also compared outcomes of patients with ESLD to patients with metastatic cancer. RESULTS: A total of 177 533 patients underwent in-hospital CPR, of which 1474 (0.8%) had ESLD. Patients with ESLD had lower rates of survival to hospital discharge compared to patients without ESLD (10.7% vs 28.6%, P < 0.01). In multivariate modelling, ESLD was significantly associated with lower odds of survival to hospital discharge after in-hospital CPR (OR 0.35, 95% CI 0.28-0.44, P < 0.01). Among survivors of in-hospital CPR, ESLD patients had a significantly lower chance of discharge to home compared to patients without ESLD (3.2% vs 8.0%, P < 0.05). Patients with ESLD also had lower rates of survival to hospital discharge compared to those with metastatic cancer (10.7% vs 15.5%, P < 0.01). CONCLUSIONS: Outcomes are poor after in-hospital CPR in patients with ESLD and are worse than for patients with metastatic cancer. The current analysis can be used to inform goals of care discussions for patients with ESLD.

Processes of code status transitions in hospitalized patients with advanced cancer.

BACKGROUND: Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown. METHODS: We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes that led to code status order transitions from full code to DNR. RESULTS: In total, 1047 hospitalizations were reviewed among 728 patients. Admitting clinicians did not address code status in 53% of hospitalizations, resulting in code status orders of "presumed full." In total, 275 patients (26.3%) transitioned from full code to DNR, and 48.7% (134 of 275 patients) of those had an order of "presumed full" at admission; however, upon further clarification, the patients expressed that they had wished to be DNR before the hospitalization. We identified 3 additional processes leading to order transition from full code to DNR acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared with discontinuing therapy and education, transitions because of acute clinical deterioration were associated with less patient involvement (P = .002), a shorter time to death (P < .001), and a greater likelihood of inpatient death (P = .005). CONCLUSIONS: One-half of code status order changes among hospitalized patients with advanced cancer were because of full code orders in patients who had a preference for DNR before hospitalization. Transitions due of acute clinical deterioration were associated with less patient engagement and a higher likelihood of inpatient death. Cancer 2017;123:4895-902. © 2017 American Cancer Society.

Barriers and facilitators for goals of care discussions between residents and hospitalised patients.

PURPOSE: To observe how residents are engaging in goals of care discussions with patients and identify thematic patterns that inhibited (barriers) and promoted discussion (facilitators) about goals of care. DESIGN: Admission encounters between residents and patients admitted to a tertiary care academic hospital were recorded and analysed using a qualitative descriptive method. Patients included in the study were individuals over the age of 65 being admitted to the internal medicine service. Residents were eligible if they were trainees in family medicine, emergency medicine, general surgery or internal medicine who were on call for the inpatient medicine rotation. RESULTS: A total of 15 resident-patient encounters were recorded and analysed, of which 12 encounters included a goals of care discussion. Barriers to goals of care discussions were due to missed opportunities to clarify patient's preferences for life-sustaining treatment and missed opportunities to engage the patient in further discussion. Facilitators to goals of care discussions were use of simple language and exploration of patient's previous experiences with life-sustaining treatment. CONCLUSIONS: Asking about patients' previous experiences with life support can be an effective strategy to gauge the patient's understanding and goals of care preferences. This knowledge can improve residents' skill in communicating with their patients about goals of care and inform future education initiatives.

Nephrologist-Facilitated Advance Care Planning for Hemodialysis Patients: A Quality Improvement Project.

BACKGROUND: The Renal Physicians Association's clinical practice guideline recommends that physicians address advance care planning with dialysis patients. However, data are lacking about how best to implement this recommendation. STUDY DESIGN: Quality improvement project. SETTINGS & PARTICIPANTS: Nephrologists caring for patients treated with maintenance hemodialysis at 2 dialysis facilities identified patients who might benefit most from advance care planning using the "surprise" question ("Would I be surprised if this patient died in the next year?"). QUALITY IMPROVEMENT PLAN: Patients identified with a "no" response to the surprise question were invited to participate in nephrologist-facilitated advance care planning, including completion of a Medical Orders for Life-Sustaining Treatment (MOLST) form. OUTCOMES: Change in MOLST completion rate and identification of preferences for limits on life-sustaining treatment. MEASUREMENTS: Pre- and postintervention code status, MOLST completion rate, and vital status at 1 year. RESULTS: Nephrologists answered "no" to the surprise question for 50 of 201 (25%) hemodialysis patients. Of these, 41 (82%) patients had a full-code status and 9 (18%) had a do-not-resuscitate (DNR) status. Encounters lasted 15 to 60 minutes. Following the encounter, 21 (42%) patients expressed preference for a DNR status and 29 (58%) maintained full-code status (P=0.001). The MOLST completion rate increased from 10% to 90%. One-year survival for patients whose nephrologists answered "no" to the surprise question was 58% compared to 92% for those with a "yes" answer (P<0.001). LIMITATIONS: Sample size and possible nonrepresentative dialysis population. CONCLUSIONS: Nephrologist-facilitated advance care planning targeting hemodialysis patients with limited life expectancy led to significant changes in documented patient preferences for cardiopulmonary resuscitation and limits on life-sustaining treatment. These changes demonstrate the benefit of advance care planning with dialysis patients and likely reflect better understanding of end-of-life treatment options.

The association between religiosity and resuscitation status preference among patients with advanced cancer.

OBJECTIVE: The potential influence of patient religious and spiritual beliefs on the approach to end-of-life care and resuscitation status preferences is not well understood. The aim of this study was to assess the association between religiosity and resuscitation preferences in advanced-cancer patients. METHOD: We performed a secondary analysis of a randomized controlled trial that evaluated the influence of physician communication style on patient resuscitation preferences. All patients completed the Santa Clara Strength of Religious Faith Questionnaire-Short Form (SCSRFQ-SF) and expressed their resuscitation preferences. We determined the frequency of resuscitation preferences and its association with intensity of religiosity. RESULTS: A total of 78 patients completed the study. The median age was 54 years, with a range of 18-78. Some 46 (59%) were women; 57 patients (73%) were Caucasian, 15 (19%) African American, and 5 (7%) Hispanic. A total of 46 patients (56%) were Protestant and 13 (17%) Catholic. Some 53 of 60 patients who chose Do Not Resuscitate status (DNR) (88%) and 16 of 18 patients who refused DNR (89%) for a video-simulated patient were highly religious (p = 0.64). When asked about a DNR for themselves after watching the videos, 43 of 48 who refused DNR (90%) and 26 of 30 patients who chose DNR (87%) were highly religious (p = 0.08). The Spearman correlation coefficient for patients choosing DNR for themselves and intensity of religiosity was r = -0.16 (p = 0.16). Some 30 patients (38%) who chose DNR for the video patient refused DNR for themselves, and 42 who chose DNR for both the video patient and themselves (54%) were highly religious (p = NS). SIGNIFICANCE OF RESULTS: There was no significant association between intensity of patient religiosity and DNR preference for either the video patient or the patients themselves. Other beliefs and demographic factors likely impact end-of-life discussions and resuscitation status preferences.

Aligning patient values and code status: Choice of Diction's Effect (CODE) study.

BACKGROUND: Decisions regarding resuscitation after cardiac arrest are critical from ethical, patient satisfaction, outcome, and healthcare cost standpoints. Physician-reported discussion barriers include topic discomfort, fear of time commitment, and difficulty articulating end-of-life concepts. The influence of language used in these discussions has not been tested. This study explored whether utilizing the alternate term "allow (a) natural death" changed code status decisions in hospitalized patients versus "do not resuscitate" (DNR). METHODS: All patients age 65 and over admitted to a general medicine hospital teaching service were screened (English-speaking, not ICU-level care, no active psychiatric illness, no substance misuse, no active DNR). Participants were randomized to resuscitation discussions with either DNR or "allow natural death" as the "no code" phrasing. Outcomes included patient resuscitation decision, satisfaction with and duration of the conversation, and decision correlation with illness severity and predicted resuscitation success. RESULTS: 102 participants were randomized to the "allow natural death" (N = 49) or DNR (N = 53) arms. The overall "no code" rate for our sample of hospitalized general medicine inpatients age >65 was 16.7%, with 13% in the DNR and 20.4% in the "allow natural death" arms (p = 0.35). Discussion length was similar in the DNR and "allow natural death" arms (3.9 + 3.2 vs. 4.9 + 3.9 minutes), and not significantly different (p = 0.53). Over 90% of participants were highly satisfied with their code status decision, without difference between arms (p = 0.49). CONCLUSIONS: Participants' code status discussions did not differ in "no code" rate between "allow natural death" and DNR arms but were short in length and had high patient satisfaction. Previously reported code status discussion barriers were not encountered. It is appropriate to screen code status in all hospitalized patients regardless of phrasing used.

A Daily Checklist Method Increases Documentation of Code Status in Trauma Patients.

OBJECTIVES: While insufficient code status documentation (CSD) is a longstanding challenge, all patients deserve the opportunity to participate in decision-making regarding code status, especially trauma patients with an unpredictable course. Prior interventions to increase CSD relied on reminder systems. We hypothesize that introducing a daily checklist will increase CSD for patients in the trauma ICU. METHODS: This quality improvement study examined the efficacy of a twice-daily checklist for improving CSD in trauma patients at a level I trauma center. A pre-intervention (PRE) and post-intervention (POST) daily census characterized the percentage of patients with CSD (primary outcome), time-to-code status (TTCS, secondary outcome) documentation, and information about patients who were discharged with no code status (DNCS, secondary outcome). RESULTS: Of 213 PRE and 207 POST, daily census CSD for all patients increased from a median of 50.0% PRE to 64.4% POST (P < .05). Time-to-code status was halved (PRE: 25.30 h, POST: 12.71 h, P < .05). Code status documentation within 12 h increased from 41.8% PRE to 60.9% POST (P < .05). Overall, the percentage of patients with CSD during their hospitalization increased 20% (PRE: 63.8%, POST: 83.6%, P < .05). Discharged with no code status patients decreased 20% (PRE: 35.2%, POST: 15.5%, P < .05). CONCLUSION: Including code status in a daily checklist involving key aspects of care for trauma patients is an effective method for improving code status documentation. Capturing code status for more patients in trauma allows us to provide patient-centered, goal-concordant care.

End-of-Life Care of a Patient With Pontine Stroke and Prolonged Hospitalization: A Case Report.

Stroke is a leading cause of long-term disability in the United States that can lead to loss of function and consciousness. With the abrupt onset of the brain insult, end-of-life care discussions are an important attribute of respecting the patient's best wishes and upholding the ethical principles of autonomy, beneficence, nonmaleficence, fidelity, and justice. Furthermore, the topic of extending life support to individuals with poor prognostic factors of improvement in quality of life and functional recovery has been a continued topic of debate due to a multitude of factors, including the wishes of the patient, familial emotions, cultural beliefs, and religious influences. This case involves a patient who suffered from a left pontine stroke, necessitating multiple end-of-life care conversations. Despite no clinical improvement for several years, the patient required prolonged hospitalization and ongoing ventilator use.