Abstract
Dear Editor:
Code status designation in a patient's electronic medical record (EMR) informs healthcare providers of the patient's desired level of care in the case of cardiopulmonary emergency. Without a standardized, single location in the EMR or a well-defined procedural standard of documentation, the potential for miscommunication regarding code status exists between providers and the patient. For patients at a higher risk of death and/or poor neurologic recovery, the question remains whether it is appropriate for providers to default to a status of full code, rather than to consider a more individually tailored, medically effective approach.
We completed a retrospective analysis of code status documentation within the EMR of metastatic pancreatic cancer patients from 2008 to 2014 at a single academic medical center. Eligibility was limited to analytical cases identified through a cancer center tumor registry. Data were organized into a single database and descriptive statistical analyses were performed. We identified 169 cases with median age of 67 years (range: 33–101 years), 47% (n = 80) were women, of which 75% (n = 127) had a code status documented. Secondary analysis included identification of the code status author and time from recording code status to time of patient's death. Of the documented cases, 44.9% were full code and 55.1% were do not resuscitate. Documentation was completed primarily by hospitalists (42.5%, n = 54) and medical residents (21.3%, n = 27), whereas the primary oncologist documented 4.7% (n = 6) of these cases. The mean ± SD difference between time of reported code status and date of patient death was 67 ± 14.5 days.
Considering historical code status documentation rates are 20%–30% for advanced solid tumor cancer patients, we were initially quite encouraged by the 75% code status documentation rate. 1 However, it is critical to recognize that code status documentation in itself may not reflect informed discussions regarding medically effective interventions, such as cardiopulmonary resuscitation (CPR), within the context of the patient's medical illness. We believe our findings suggest providers to “default” to full code for patients. Full code should be the exception and not the rule for patients where the data clearly demonstrate a hastened death and/or poor neurologic outcomes after CPR. We believe offering a medically ineffective interventions to patients conflicts with quality medical care. In fact, when patients are informed and receive honest discussions concerning code status, they frequently choose not to have CPR. 2 Solutions should focus on routine code status discussions in the outpatient oncology setting with providers that patients interact with and trust. Another collaborative approach focuses on integrating outpatient palliative care with outpatient oncology, which has shown increased prognostic understanding and discussions regarding preferences at the end of life. 3 Despite increasing access to inpatient palliative care services nationally, there has been limited growth of outpatient palliative care, limiting our ability to incorporate these services upstream. 4 We offer our institutional experience as an example of an opportunity for quality improvement, speculate this challenge exists in other settings, and hope our discussion spurs the development of possible solutions.