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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.
Background:
Code status discussions are often inadequate, omitting key information on prognosis and resuscitation risks. In the randomized controlled CLEAR trial, use of a checklist to guide shared decision-making for code status discussions improved the quality of care by reducing patients' uncertainty and increasing their satisfaction with discussions and knowledge of this topic. Moreover, a higher rate of "do-not-resuscitate" (DNR) code status preference was observed during the index hospital stay. The present analysis evaluates whether these effects were sustained over time.
Objective:
To evaluate the documented code status (primary outcome) and exploratory secondary outcomes, including patients' general knowledge about resuscitation measures after a mean follow-up time of 3.2 years, assessed by telephone interview.
Design:
Long-term follow-up of a prospective, randomized controlled study.
Participants:
Of the 1954 medical inpatients in the previous CLEAR trial, 604 had died and 10 were excluded due to missing information, leaving 1340 patients for analysis (mean age 65.0 (SD ± 16.3) years, 44.1% female).
Interventions:
Code status discussions using a shared decision-making checklist including visual decision support addressing prognosis, resuscitation outcomes, and patient values compared to usual care.
Main Measures:
Last documented code status at follow-up.
Key Results:
Patients in the intervention group had a significantly higher rate of documented DNR status at follow-up compared to patients in the usual care group (251 [36.1%] vs. 191 [29.8%]; adjusted risk ratio 1.23, 95% CI 1.04 to 1.45, p = 0.02). No significant differences were observed in knowledge about resuscitation measures.
Conclusions:
Several years after a shared decision-making code status discussion, patients recalled little specific knowledge about resuscitation measures and their prognostic outcomes. However, the intervention group maintained a higher documented preference for DNR. These results highlight the need for repeated discussions, including prognosis and expected outcomes, to support informed and consistent decision-making.
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