Comparing approaches to code status conversations between Thai and American emergency clinicians: a survey study

Emergency clinicians conduct code status conversations as part of shared decision-making regarding the management of patients with serious life-limiting illnesses. Given that varying sociocultural norms and healthcare systems affect communication, we hypothesised that American and Thai emergency clinicians report different approaches to code status conversations.

A cross-sectional survey study was conducted in one US hospital and four Thai hospitals from December 2021 to November 2022. Using a 5-point Likert Scale, the survey questions focused on clinical practice for procedure-based and value-based components of code status conversations. We developed the survey from a medical communication expert team and then reviewed, refined and validated the questions. Multiple logistic regression analysis was used to compare the asking in code status conversation among American and Thai emergency clinicians and controlled for potential confounding variables.

We received responses from 84 American and 81 Thai emergency clinicians (74% and 70%, respectively). Most of the participants had 6-10 years of clinical experience (n=71, 43%), had code status conversations more than twice each month (n=63, 38%), and had prior palliative care training (n=141, 86%). Over 50% of all emergency clinicians responded 'very likely' or 'somewhat likely' to incorporate all six procedure-based components but only one of the six value-based components. Compared with Thai emergency clinicians, American emergency clinicians were significantly more likely to ask one procedure-based component (restarting the patient's heart, adjusted OR (aOR) =9.3 (95% CI 3.2 to 26.8)), while less likely to ask another procedure-based component (the patient's preference for vasopressors, aOR=0.3 (95% CI 0.1 to 0.7)), and two value-based components (providing a recommendation, aOR=0.2 (95% CI 0.1 to 0.5), assessing the patient's baseline activity, aOR=0.2 (95% CI 0.1 to 0.4)).

In the approaches to code status conversations, American and Thai emergency clinicians collectively report asking about procedures rather than personal values, while specific distinctions exist and potentially reflect different cultural approaches.