Code Status Orders and Goals of Care in the Medical ICU

Background Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care. Methods We interviewed 100 patients, or their surrogates, and their physicians in an MICU. W...

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Veröffentlicht in:Chest 2011-04, Vol.139 (4), p.802-809
Hauptverfasser: Gehlbach, Thomas G., MD, Shinkunas, Laura A., BA, Forman-Hoffman, Valerie L., PhD, MPH, Thomas, Karl W., MD, Schmidt, Gregory A., MD, FCCP, Kaldjian, Lauris C., MD, PhD
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container_end_page 809
container_issue 4
container_start_page 802
container_title Chest
container_volume 139
creator Gehlbach, Thomas G., MD
Shinkunas, Laura A., BA
Forman-Hoffman, Valerie L., PhD, MPH
Thomas, Karl W., MD
Schmidt, Gregory A., MD, FCCP
Kaldjian, Lauris C., MD, PhD
description Background Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care. Methods We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders. Results Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents' average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status ( P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care. Conclusions Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients' code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.
doi_str_mv 10.1378/chest.10-1798
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However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care. Methods We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders. Results Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents' average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status ( P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care. Conclusions Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients' code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.</description><identifier>ISSN: 0012-3692</identifier><identifier>EISSN: 1931-3543</identifier><identifier>DOI: 10.1378/chest.10-1798</identifier><identifier>PMID: 21292755</identifier><identifier>CODEN: CHETBF</identifier><language>eng</language><publisher>Northbrook, IL: American College of Chest Physicians</publisher><subject>Biological and medical sciences ; Cardiology. Vascular system ; Cardiopulmonary Resuscitation - standards ; Female ; Goals ; Health Knowledge, Attitudes, Practice ; Humans ; Intensive Care Units - organization &amp; administration ; Male ; Medical sciences ; Middle Aged ; Original Research ; Patient Care Planning - organization &amp; administration ; Pneumology ; Pulmonary/Respiratory ; Resuscitation Orders ; Retrospective Studies</subject><ispartof>Chest, 2011-04, Vol.139 (4), p.802-809</ispartof><rights>The American College of Chest Physicians</rights><rights>2015 INIST-CNRS</rights><rights>2011 American College of Chest Physicians 2011</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c471t-8842c843a6fcd919aa4ee30f8403c45369ea8628d1d8b5ba4cfac92fe1c4c3ab3</citedby><cites>FETCH-LOGICAL-c471t-8842c843a6fcd919aa4ee30f8403c45369ea8628d1d8b5ba4cfac92fe1c4c3ab3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>230,314,780,784,885,27924,27925</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&amp;idt=24091701$$DView record in Pascal Francis$$Hfree_for_read</backlink><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/21292755$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Gehlbach, Thomas G., MD</creatorcontrib><creatorcontrib>Shinkunas, Laura A., BA</creatorcontrib><creatorcontrib>Forman-Hoffman, Valerie L., PhD, MPH</creatorcontrib><creatorcontrib>Thomas, Karl W., MD</creatorcontrib><creatorcontrib>Schmidt, Gregory A., MD, FCCP</creatorcontrib><creatorcontrib>Kaldjian, Lauris C., MD, PhD</creatorcontrib><title>Code Status Orders and Goals of Care in the Medical ICU</title><title>Chest</title><addtitle>Chest</addtitle><description>Background Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care. Methods We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders. Results Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents' average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status ( P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care. Conclusions Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients' code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.</description><subject>Biological and medical sciences</subject><subject>Cardiology. Vascular system</subject><subject>Cardiopulmonary Resuscitation - standards</subject><subject>Female</subject><subject>Goals</subject><subject>Health Knowledge, Attitudes, Practice</subject><subject>Humans</subject><subject>Intensive Care Units - organization &amp; administration</subject><subject>Male</subject><subject>Medical sciences</subject><subject>Middle Aged</subject><subject>Original Research</subject><subject>Patient Care Planning - organization &amp; administration</subject><subject>Pneumology</subject><subject>Pulmonary/Respiratory</subject><subject>Resuscitation Orders</subject><subject>Retrospective Studies</subject><issn>0012-3692</issn><issn>1931-3543</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2011</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNpVkU1v1DAQhi0EosvCkSvyBXFK8dhOYl-QUASlUlEPpWdr1pmwLtm42Eml_nu87faDkzXyo3dmnmHsPYhjUK357LeU52MQFbTWvGArsAoqVWv1kq2EAFmpxsoj9ibnK1FqsM1rdiRBWtnW9Yq1XeyJX8w4L5mfp55S5jj1_CTimHkceIeJeJj4vCX-k_rgceSn3eVb9mooBL07vGt2-f3br-5HdXZ-ctp9Pau8bmGujNHSG62wGXxvwSJqIiUGo4Xyui6zEZpGmh56s6k3qP2A3sqBwGuvcKPW7Mt97vWy2VHvaZoTju46hR2mWxcxuP9_prB1v-ONU2CNtlACPh0CUvy7FFduF7KnccSJ4pKdaYQxAoqwNavuSZ9izomGxy4g3N61u3N9VxXXhf_wfLRH-kFuAT4eAMxF25Bw8iE_cVpYaAU87UhF5E2g5PwYpr3pP3RL-SouaSqOHbgsnXAX-7PurwrQCDBCqX_LN5wV</recordid><startdate>20110401</startdate><enddate>20110401</enddate><creator>Gehlbach, Thomas G., MD</creator><creator>Shinkunas, Laura A., BA</creator><creator>Forman-Hoffman, Valerie L., PhD, MPH</creator><creator>Thomas, Karl W., MD</creator><creator>Schmidt, Gregory A., MD, FCCP</creator><creator>Kaldjian, Lauris C., MD, PhD</creator><general>American College of Chest Physicians</general><scope>IQODW</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20110401</creationdate><title>Code Status Orders and Goals of Care in the Medical ICU</title><author>Gehlbach, Thomas G., MD ; Shinkunas, Laura A., BA ; Forman-Hoffman, Valerie L., PhD, MPH ; Thomas, Karl W., MD ; Schmidt, Gregory A., MD, FCCP ; Kaldjian, Lauris C., MD, PhD</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c471t-8842c843a6fcd919aa4ee30f8403c45369ea8628d1d8b5ba4cfac92fe1c4c3ab3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2011</creationdate><topic>Biological and medical sciences</topic><topic>Cardiology. Vascular system</topic><topic>Cardiopulmonary Resuscitation - standards</topic><topic>Female</topic><topic>Goals</topic><topic>Health Knowledge, Attitudes, Practice</topic><topic>Humans</topic><topic>Intensive Care Units - organization &amp; administration</topic><topic>Male</topic><topic>Medical sciences</topic><topic>Middle Aged</topic><topic>Original Research</topic><topic>Patient Care Planning - organization &amp; administration</topic><topic>Pneumology</topic><topic>Pulmonary/Respiratory</topic><topic>Resuscitation Orders</topic><topic>Retrospective Studies</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Gehlbach, Thomas G., MD</creatorcontrib><creatorcontrib>Shinkunas, Laura A., BA</creatorcontrib><creatorcontrib>Forman-Hoffman, Valerie L., PhD, MPH</creatorcontrib><creatorcontrib>Thomas, Karl W., MD</creatorcontrib><creatorcontrib>Schmidt, Gregory A., MD, FCCP</creatorcontrib><creatorcontrib>Kaldjian, Lauris C., MD, PhD</creatorcontrib><collection>Pascal-Francis</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Chest</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Gehlbach, Thomas G., MD</au><au>Shinkunas, Laura A., BA</au><au>Forman-Hoffman, Valerie L., PhD, MPH</au><au>Thomas, Karl W., MD</au><au>Schmidt, Gregory A., MD, FCCP</au><au>Kaldjian, Lauris C., MD, PhD</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Code Status Orders and Goals of Care in the Medical ICU</atitle><jtitle>Chest</jtitle><addtitle>Chest</addtitle><date>2011-04-01</date><risdate>2011</risdate><volume>139</volume><issue>4</issue><spage>802</spage><epage>809</epage><pages>802-809</pages><issn>0012-3692</issn><eissn>1931-3543</eissn><coden>CHETBF</coden><abstract>Background Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care. Methods We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders. Results Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents' average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status ( P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care. Conclusions Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients' code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.</abstract><cop>Northbrook, IL</cop><pub>American College of Chest Physicians</pub><pmid>21292755</pmid><doi>10.1378/chest.10-1798</doi><tpages>8</tpages><oa>free_for_read</oa></addata></record>
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subjects Biological and medical sciences
Cardiology. Vascular system
Cardiopulmonary Resuscitation - standards
Female
Goals
Health Knowledge, Attitudes, Practice
Humans
Intensive Care Units - organization & administration
Male
Medical sciences
Middle Aged
Original Research
Patient Care Planning - organization & administration
Pneumology
Pulmonary/Respiratory
Resuscitation Orders
Retrospective Studies
title Code Status Orders and Goals of Care in the Medical ICU
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