Code status documentation in the outpatient electronic medical records of patients with metastatic cancer

Advanced care planning (ACP) is considered an essential component of medical care in the United States, especially in patients with incurable diseases. However, little is known about clinical practices in outpatient oncology settings related to discussing end-of-life care and documenting code status preferences in ambulatory medical records.

To assess the rate of documentation of code status in the electronic longitudinal medical records (LMR) of patients with metastatic cancer.

Retrospective review of 2,498 patients with metastatic solid tumors at an academic cancer center. An electronic patient database and the LMR were queried to identify demographic information, cancer type, number of clinic visits, and documentation of code status.

The sample consisted of adult patients with metastatic prostate, breast, ovarian, bladder kidney, colorectal, non-colorectal gastrointestinal (GI), and lung cancers.

Primary outcome was the percentage of documented code status in the LMR.

Among the 2,498 patients, 20.3% had a documented code status. Code status was designated most frequently in patients with non-colorectal GI (193/609, 31.7%) and lung (179/583, 30.7%) cancers and least frequently in patients with genitourinary malignancies [bladder/kidney (4/89, 4.5%), ovarian (4/93, 4.3%), and prostate (7/365, 1.9%) cancers]. Independent predictors of having documented code status included religious affiliation, cancer type, and a greater number of visits to the cancer center. Younger patients and black patients were less likely to be designated as DNR/DNI.

Despite the incurable nature of metastatic cancer, only a minority of patients had a code status documented in the electronic medical record.