Factors Influencing Physicians' Code Status Decision-Making: An Experimental Vignette-Based Survey

Worldwide hospitals increasingly require a code status to be established for every inpatient. Establishing a code status should be a shared decision-making process between the inpatient and the hospital physician. However, there is no consensus on how code status should be established at admission and which factors influence the decision-making process.

To identify physician and patient characteristics influencing physicians' code status decision-making.

Experimental, vignette-based survey in a tertiary university hospital, using a self-report online vignette questionnaire. Each questionnaire contained eleven demographic questions and five clinical vignettes. Three vignettes had one variable altered between two groups, and two vignettes were identical in the two groups. Participants were physicians working in hospital wards admitting adult somatic patients. Physicians were randomly assigned to one of the two groups and had to decide on a code status in case of a cardiac arrest.

Among 724 invited physicians, 303 (41.8%) participated in this study, 146 in group A and 157 in group B. Physicians from surgery departments were significantly (p < 0.001) more likely to resuscitate than those from the medicine department in four vignettes (multimorbidity, oncology, dementia, and neurology vignettes). Physicians with experience in ICU were significantly (p < 0.05) less likely to recommend resuscitation in three vignettes (multimorbidity, oncology and dementia vignettes). Two patient variables were significantly (p < 0.001) associated with a decision to resuscitate: patient being a physician themself versus not (33.1% vs. 15.8%); younger versus older patient (61.5% vs. 25.5%) despite a terminally ill condition.

Physicians' own characteristics contribute to heterogeneity in decision-making. Physicians' decision-making regarding code status is influenced by patient factors that may not be related to resuscitation outcomes. These results raise important ethical considerations and highlight the need for specific training about code status conversations, resuscitation outcomes, and reflexiveness in decision-making.