A Pilot Study to Evaluate Compliance with Guidelines for Preprocedural Reconsideration of Code Status Limitations

Introduction

As palliative procedures performed near the end of life become more common, periprocedural providers increasingly care for patients who have code status limitations (CSLs) regarding their preferences for resuscitation and life-sustaining treatment. Among Medicare recipients who died in 2008, 32% had an inpatient surgical procedure performed within their last year of life and 18% within their last month of life.^1,2 Malignant bowel obstruction (MBO) is a common indication for palliative intervention, often treated with placement of a venting gastrostomy tube (VGT), ³ although 90% of patients treated with VGT die within six months of the procedure. ⁴

Automatic suspension or enforcement of CSLs—that is, the limits placed on the types of resuscitative efforts permitted during a procedure—is considered unethical in that removing the patient from decision making regarding code status fails to respect patient autonomy.^5–7 Instead, providers are expected to discuss code status in the context of procedural risk. The provider should then confirm, suspend, or modify the CSL based on the patient's preference. This process has been endorsed in official position statements published by the American Society of Anesthesiologists (ASA), the American College of Surgeons (ACS), and the Association of Perioperative Registered Nurses (AORN).^8–10 However, the extent to which existing guidelines have been incorporated into practice is not known.

We sought to determine the rate of compliance with these guidelines for preprocedural reconsideration of CSLs in the care of patients undergoing VGT placement for MBO.

Materials and Methods

This study was approved by the Partners Health Care Human Research Committee. This study complies with the STROBE Statement for reporting observational studies.

Results

We identified 53 patients who underwent a VGT procedure during this two-year period (Table 1). This group was 68% female, median age of 61 years, and had a median survival of 34 days postdischarge. Interventional radiologists performed 88% of VGT procedures, whereas surgeons and gastroenterologists performed 10% and 2% of cases, respectively. Anesthesiologists were involved in 23% of cases.

Before the VGT procedure, 57% of patients were full code and 43% had a CSL. Compliance with guidelines for preprocedural reconsideration of CSLs is shown in Figure 1. We next examined CSDs—that is, actual discussions that took place and involved the patient or patient's family and the healthcare provider. We categorized CSDs into three categories: (i) documented CSD wherein the code status remained unchanged, (ii) documented CSD wherein the code status was modified, and (iii) no documented CSD. Among 23 patients with CSLs, 22% had a CSD with a periprocedural provider before the procedure. Of those patients, two confirmed their CSLs, whereas three patients modified their CSLs for the procedure. Only one of three patients who modified their CSLs had documentation of a plan for reinstatement of CSLs after the procedure. Of all patients with CSLs before the VGT procedure, 13% of cases (3 patients) were compliant with the guidelines of preprocedural reconsideration of CSLs, whereas 87% of cases (20 patients) were not. Examples of documentation of CSDs are represented in Table 2.

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FIG. 1.

Documented discussions of CSLs with patients undergoing VGT placement for MBO (n = 23). CSLs, code status limitations; MBO, malignant bowel obstruction; VGT, venting gastrostomy tube.

Discussion

We found that only 43% of patients receiving a VGT for an MBO had CSLs before the procedure. Furthermore, only 22% of these patients had documentation of a CSD with a periprocedural provider, and documentation was incomplete in 40% of those cases.

Our findings are not surprising in light of recent studies on the management of CSLs by periprocedural providers. For example, a recent survey of 69 surgeons and anesthesiologists found that only 34% confirmed the presence of an advance directive before taking a critically ill patient to the operating room, ¹³ and a survey of 132 anesthesiologists reported that >60% would automatically suspend a DNR order in the perioperative period. ¹⁴ The latter study conducted a simulation in which a subset of anesthesiologists performed a preprocedural evaluation of a patient with metastatic cancer and a documented DNR order. Surprisingly, 27% of participants did not note the DNR order during the evaluation, and only 57% of those who did addressed resuscitation with the patient. When surgical patients were asked about their preferences regarding limitations on resuscitation, 92% felt that there should be a preoperative discussion about the subject. ¹⁵

Since a variety of periprocedural providers may be involved in the care of patients undergoing palliative procedures, it is vital that all of these providers be prepared to manage CSLs. Although professional organizations such as the ASA, ACS, and AORN have released statements in support of preprocedural reconsideration of CSLs,^8–10 we are not aware of statements by interventional radiologists or gastroenterologists. The Joint Commission has put forth limited standards for DNR management, essentially leaving individual hospitals to design their own policies, ¹⁶ and does not address the unique circumstances surrounding CSLs in the setting of a procedure. The high frequency of CSLs found within this study underscores the need for providers to be competent in eliciting and documenting patients' resuscitation preferences under these circumstances. A unified message endorsing preprocedural reconsideration of CSLs by hospital oversight committees and other proceduralist societies would be an important next step in bringing this issue to the awareness of all periprocedural providers.

Compliance with these guidelines ensures that each patient with CSLs will have an opportunity to make a fully informed decision about their code status wishes for the periprocedural period. Increased compliance with these guidelines is necessary to ensure goal-concordant care of patients with CSLs who undergo a procedure, and efforts should be made to incorporate these guidelines into the training of all periprocedural providers. Our data show that this does not occur in the majority of cases, making these patients vulnerable to miscommunication and mismanagement by providers if resuscitation measures were required during a procedure. Recent litigation against hospitals that have resuscitated patients with documented CSLs ¹⁷ underscores the importance of discussing CSLs with patients before they undergo a procedure, to ensure that the patient understands the risks unique to the situation and providers have a clear understanding of the patient's wishes. Where they exist, release of position statements has not been sufficient to motivate the integration of preprocedural reconsideration guidelines. Other approaches may include targeted education of providers and development and incorporation of decision support tools into the EHR to better enable these discussions to occur as part of regular workflow. This may be in the form of a checklist, a risk calculator, or direct access to existing evidence and relevant guidelines. Giving providers access to information such as survival data for the given condition and the planned intervention is also critical because the disease survival is usually measured in weeks or months, and this should be factored into the CSDs.

The generalizability of this study is limited by the small number of eligible patients identified. This study is also limited by any bias introduced due to its retrospective design. Because evidence of CSDs was collected through chart review, we were not able to identify discussions that occurred but were not documented. However, even if reconsideration of CSLs was discussed yet never documented because patients did not want to change CSLs, failure to document these discussions is in itself noncompliant with published guidelines.

Our findings suggest that despite recommendations of professional associations, current practices of documentation do not meet the standards for preprocedural reconsideration of CSLs. Therefore, it is imperative that periprocedural providers take steps to standardize practices and education^18–20 within their hospitals and professional groups to provide goal-concordant care to their end-of-life patients.