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Does Checklist-Guided Shared Decision Making Have a Sustained Effect on Code Status Decisions Among Medical
Benjamin Bissmann1, Samuel K Zumbrunn1, Sebastian Gross1
1Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland.
Journal of General Internal Medicine
|April 14, 2026
Summary
A checklist improved code status discussions, leading to more documented do-not-resuscitate (DNR) preferences long-term. However, patient knowledge of resuscitation measures did not significantly improve, indicating a need for repeated discussions.
Area of Science:
- Medical Ethics
- Patient Decision-Making
- Healthcare Quality Improvement
Background:
- Code status discussions are frequently inadequate, lacking crucial prognostic and resuscitation risk information.
- The CLEAR trial demonstrated that a checklist improved shared decision-making for code status, reducing patient uncertainty and enhancing satisfaction.
- The intervention also increased the rate of do-not-resuscitate (DNR) preferences during the initial hospital stay.
Purpose of the Study:
- To assess the long-term sustainability of documented code status preferences following a shared decision-making intervention.
- To evaluate patients' general knowledge of resuscitation measures at a mean follow-up of 3.2 years.
- To determine if the benefits of the CLEAR trial's checklist intervention persisted over time.
Main Methods:
- Long-term follow-up of a prospective, randomized controlled study.
- Analysis included 1340 patients from the original CLEAR trial.
- Intervention involved code status discussions using a shared decision-making checklist with visual decision support compared to usual care.
Main Results:
- Patients in the intervention group maintained a significantly higher rate of documented DNR status at follow-up (36.1% vs. 29.8%).
- The adjusted risk ratio for documented DNR status was 1.23 (95% CI 1.04 to 1.45, p=0.02).
- No significant differences were found in patients' knowledge about resuscitation measures between groups.
Conclusions:
- While the intervention group sustained a higher documented preference for DNR status years later, specific knowledge of resuscitation measures remained limited.
- These findings underscore the importance of repeated code status discussions, including prognosis and expected outcomes.
- Consistent, informed decision-making requires ongoing patient engagement and reinforcement of information.
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