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Published on: October 24, 2020
Checklist-Guided Code Status Discussions in Patients for Whom Cardiopulmonary Resuscitation Is Considered Futile: An
Armon Arpagaus1,2, Leta Arpagaus1, Christoph Becker1,3
1Division of Medical Communication/Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland.
Insights
Structured code status discussions using a checklist reduced ICU admission preferences in futile cardiopulmonary resuscitation (CPR) patients. This approach also eased physician challenges without negatively impacting patient psychological burden.
Area of Science:
- Medical Ethics
- Clinical Communication
- Palliative Care
Background:
- Code status discussions are crucial for advanced care planning but pose challenges for clinicians when cardiopulmonary resuscitation (CPR) is considered futile.
- Effective communication strategies are needed to navigate these complex discussions.
Purpose of the Study:
- To evaluate the impact of a structured communication approach on code status decisions and quality-of-care measures in patients with futile CPR.
- To assess the effect on patients' psychological burden and physicians' perceptions of the discussions.
Main Methods:
- The GUIDE trial was a multicenter randomized clinical trial involving medical inpatients with futile CPR (GOAL-7 score ≥14 or CFS score ≥7).
- Patients were randomized to either a checklist-guided discussion or usual care.
- Outcomes included code status, preference for mechanical ventilation and ICU admission, patient psychological burden, and physician perceptions.
Main Results:
- A total of 177 patients were studied; 85% had do-not-resuscitate orders.
- No significant difference in do-not-resuscitate orders between groups (89% vs 82%).
- Patients in the checklist group showed a reduced preference for ICU admission (36% vs 52%, P=.046) and physicians found discussions less challenging (P=.006).
- No significant difference in patients' psychological burden was observed.
Conclusions:
- Checklist-guided code status discussions effectively reduce ICU admission preferences in patients with futile CPR.
- This structured approach alleviates physician challenges during these discussions.
- The intervention does not adversely affect patients' psychosocial burden, supporting its clinical relevance.
Importance:
Code status discussions represent a fundamental aspect of advanced care planning and impose major challenges for clinicians in patients for whom cardiopulmonary resuscitation (CPR) is considered futile.
Objective:
To investigate the effect of a structured communication approach in code status discussions on decisions regarding code status and various quality-of-care measures for patients in whom resuscitation is considered futile.
Design, Setting, And Participants:
The GUIDE trial is a multicenter randomized clinical trial, which included patients deemed futile regarding CPR measures. The study was conducted between June 1, 2019, and April 30, 2023, in medical inpatients wards across 6 Swiss teaching hospitals. Medical inpatients for whom CPR measures were considered futile based on a prearrest Good Outcome Following Attempted Resuscitation score of 14 or higher or a Clinical Frailty Scale score of 7 or higher were eligible. Patients with cognitive or physical condition hindering meaningful conversation were excluded.
Main Outcomes And Measures:
Main outcomes included patients' code status decisions as well as preference for mechanical ventilatory assistance and intensive care unit admission. Additional outcomes assessed patients' psychological burden after the discussion measured by the State-Trait Anxiety Inventory and Hospital Anxiety and Depression scale and physicians' perception regarding the discussions.
Results:
A total of 177 patients (mean [SD] age, 76.3 [12.0] years; 90 [51%] female) were studied. Overall, the rate of do-not-resuscitate orders was 85%. No significant difference was observed between groups (checklist vs usual care group, 79 of 89 [89%] vs 72 of 88 [82%]; odds ratio, 1.76; 95% CI, 0.75-4.12; P = .20). However, patients in the checklist group were less likely to prefer intensive care unit admission compared with usual care (31 of 89 [36%] vs 44 of 88 [52%]; odds ratio, 0.53; 95% CI, 0.29-0.99; P = .046). Physicians perceived code status discussions using the checklist less challenging (mean [SD], 3.5 [2.8] vs 4.7 [2.8]; difference, -1.23; 95% CI, -2.1 to -0.35; P = .006). There was no significant difference in patients' psychological reaction to code status discussions measured by State-Trait Anxiety Inventory and Hospital Anxiety and Depression scale.
Conclusions And Relevance:
This analysis of a randomized clinical trial found that checklist-guided code status discussions in patients for whom CPR was considered futile reduced their preference for intensive care unit admission while alleviating physicians' challenges during code status discussions without adversely affecting patients' psychosocial burden.
Trial Registration:
ClinicalTrials.gov Identifier: NCT03872154.
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