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Context: Cardiopulmonary resuscitation is one of the most important end-of-life care decisions. However, the experience of bereaved families during code status discussions is not well documented.Objective: The aims of this study were to describe the degree of emotional distress of bereaved families when discussing code status, identify their perceived areas for improvement and determine associated factors.Methods: This study is part of a nationwide post-bereavement survey, the Japan Hospice and Palliative care Evaluation 3 (J-HOPE3) study. Questionnaires were sent to the relatives of cancer patients who had died in palliative care units in Japan in 2014.Results: From an analysis of 338 questionnaires, 37% of families reported high emotional distress during code status discussions and 32% reported a need for improvement. Multiple logistic regression analyses revealed the following were associated with high-level distress: the family had hoped for the miraculous and spontaneous recovery of the patient (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.31-4.43, P = 0.0049), the family felt they could not voice their opinion about Cardiopulmonary resuscitation (OR 2.07, CI 1.12-3.81, P = 0.02), or the physician failed to adapt the explanation to the family's preparation level (OR 0.36, CI 0.18-0.68, P = 0.0015). Factors identified for improvement were: holding discussions in a relaxing atmosphere conducive to questioning (OR 0.36, CI 0.16-0.80, P = 0.012), and ensuring the physician adapted the explanation to the family's preparation level (OR 0.47, CI 0.23-0.96, P = 0.037).Conclusion: We recommend the development of educational programs for code status discussions to improve the experience of bereaved family members. [ABSTRACT FROM AUTHOR]

INTRODUCTION Code status discussions are useful for understanding patients’ preferences in the case of a cardiac/pulmonary arrest. These discussions can also provide patients with a basis for informed decision-making regarding life-sustaining treatment. We conducted a survey to understand current practices and perceptions of code status discussions in a tertiary-care Swiss hospital. METHODS We performed systematic interviews across different departments of the University Hospital of Basel. We interviewed 258 physicians and 145 patients who were hospitalised between May and July 2018 using a questionnaire designed to assess the use of code status discussions and to gauge patients’ individual experiences and opinions. RESULTS A total of 61.4% of patients did not recall having had a code status discussion during the hospital stay. However, a higher proportion of medical patients compared to surgical patients recalled having had a discussion (43.6 vs 22.4%, p = 0.03). For 9 out of 38 (23.7%) patients who did recall the discussion, there was a lack of agreement between the preference given in the interview regarding resuscitation measures and the documented code status in the medical electronic chart. Furthermore, a majority of physicians (72.4%) recalled defining a do-not-resuscitate (DNR) status for a patient without prior discussion with the patient. Physicians who recalled determining the DNR status without patient consultation reported conflicts with patients and relatives regarding code status at a higher rate compared to physicians who did not define DNR status without consultation (62.4 vs 39.4%, p

Akinori Sasaki,1 Eiji Hiraoka,1 Yosuke Homma,2 Osamu Takahashi,3 Yasuhiro Norisue,4 Koji Kawai,5 Shigeki Fujitani4 1Department of Internal Medicine, 2Department of Emergency Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba, 3Department of Internal Medicine, St. Luke’s International Hospital, Chuo-ku, Tokyo, 4Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba, 5Department of Gastroenterology, Ito Municipal Hospital, Ito City, Shizuoka, Japan Background: Code status discussion is associated with a decrease in invasive procedures among terminally ill cancer patients. We investigated the association between code status discussion on admission and incidence of invasive procedures, cardiopulmonary resuscitation (CPR), and opioid use among inpatients with advanced stages of cancer and noncancer diseases. Methods: We performed a retrospective cohort study in a single center, Ito Municipal Hospital, Japan. Participants were patients who were admitted to the Department of Internal Medicine between October 1, 2013 and August 30, 2015, with advanced-stage cancer and noncancer. We collected demographic data and inquired the presence or absence of code status discussion within 24 hours of admission and whether invasive procedures, including central venous catheter placement, intubation with mechanical ventilation, and CPR for cardiac arrest, and opioid treatment were performed. We investigated the factors associated with CPR events by using multivariate logistic regression analysis. Results: Among the total 232 patients, code status was discussed with 115 patients on admission, of which 114 (99.1%) patients had do-not-resuscitate (DNR) orders. The code status was not discussed with the remaining 117 patients on admission, of which 69 (59%) patients had subsequent code status discussion with resultant DNR orders. Code status discussion on admission decreased the incidence of central venous catheter placement, intubation with mechanical ventilation, and CPR in both cancer and noncancer patients. It tended to increase the rate of opioid use. Code status discussion on admission was the only factor associated with the decreased use of CPR (P

Background: Code status discussions (CSDs) can be challenging for many clinicians. Barriers associated with them include lack of education, comfort level, and experience. Objective: To conduct an educational intervention to improve knowledge and communication approaches related to CSDs. Design: A cross-sectional multidisciplinary educational intervention was conducted over one year consisting of an interactive presentation, live role-play, and pre- and post-intervention tests to measure impact of the formal training. Evaluations and comments were also collected. Setting/Subjects: Attending physicians, nurses, residents, fellows, and physician assistants (PAs) at an urban community teaching hospital of 500 beds serving an ethnically diverse population. Measurements: Data from pre- and post-intervention tests evaluating knowledge and communication approach regarding CSDs were collected. Participants completed a qualitative evaluation of the program. Results: There were 165 participants: 29 attending physicians, 26 residents, 17 fellows, 18 PAs, and 75 nurses. All (100%) completed the pre-intervention test and 154 (93.3%) completed the post-intervention test. There was an overall improvement in scores, 43.8% pre-intervention to 75.6% post-intervention (p-values <0.005). Attending physicians and fellows had the highest pre-intervention scores, while nurses and PAs had the lowest. Most participants (97%) reported they learned new information and 91% stated they would change patient management. Conclusions: Our study found that a brief educational intervention with multipronged teaching tools improved knowledge concerning CSDs. Participants felt it provided new insights and would change their practice. This study contributes to the literature by examining CSD training across different disciplines, allowing for cross-group comparisons. Future studies should try to correlate educational interventions and clinician knowledge with clinical practice outcomes. [ABSTRACT FROM AUTHOR]

Background: Obstetrics and gynecology (OB/GYN) residents receive little formal training in conducting code status discussions (CSDs). Objective: We piloted an educational intervention to improve resident confidence and competence at conducting CSDs. Design: The OB/GYN residents at a single institution participated in a 3-part educational program. First, participants reviewed a journal article and completed an online module. Second, they received a didactic lecture followed by a resident-to-resident mock CSD. Finally, participants had a videotaped CSD with a standardized patient (SP). Pre- and postintervention surveys and performance evaluations were analyzed. A subgroup analysis was performed on those with completed data sets. Results: Participants included 24 residents in postgraduate years (PGY) 1 to 4: 85% were female with a mean age of 29 years; 83% completed the entrance survey; 63% completed the SP CSD; and 42% completed of all parts of the intervention. Residents initially felt most prepared to discuss treatment options (3.3/5 on a Likert scale) and less prepared to discuss hospice, end-of-life care, and code status (2.2/5, 2.2/5, and 2.3/5, respectively). Performance during the resident-to-resident CSD was variable with scores (% of skills achieved) ranging from 27% to 93% (mean 64%). Performance at the SP encounter was similar with scores ranging from 40% to 73% (mean 56%). After intervention, residents felt more prepared for CSDs (3.7/5) and end-of-life care (3.9/5). The subgroup analysis failed to show a significant change in skill performance from the first to the second CSD. Conclusion: Participants found the components of this intervention helpful and reported improved confidence at conducting CSDs. [ABSTRACT FROM AUTHOR]

Abstract Introduction Experts on code status discussions have recommended and utilized a particular approach to the code status discussion that involves eliciting patient goals, and recommending a code status if one aligns with those goals. Yet residents who conduct the majority of the code status discussions at academic institutions rarely receive training to help them meet these guidelines and recommendations, and may therefore lack the skills necessary to conduct the code status discussion. This curriculum arose out of a perceived need to offer internal medical residents a standardized curriculum, grounded in existing guidelines and evidence, which would allow them to become more skilled and comfortable with code status discussions. Methods The curriculum aims to take experts' best practices for the code status discussion and make them both available to and appropriate for early trainees. The curriculum consists of two sessions of approximately 1 hour each, both based on PowerPoint presentations formatted to spark extensive discussion amongst learners. The curriculum can be taught by anyone with moderate experience with code status discussions and is designed to minimize the planning required on the part of the instructor. Results We piloted this curriculum with 15 interns during the 2013-2014 academic year. Immediately after participation in the curriculum, the interns were surveyed anonymously about the curriculum and we solicited in-person feedback. One hundred percent of participants could accurately state usual code outcomes after participating in the curriculum, compared to just 40% beforehand. When asked if they'd recommend the curriculum to future interns (1 = definitely not, 5 = definitely), their average response was 4.5. When asked how well the sessions prepared them to engage in further code status discussions with real patients, they rated them as 4.3, on average, and they gave an average rating of 4.6 when asked how effective the curriculum's examples were in giving them ideas for phrasing to use in real patient conversations. They average response to “How comfortable would you feel using this new framework in a code status discussion?” was 4.0. When asked to perform blind recall of the seven steps in the described process, the group overall recalled the steps 81% correctly. Representative narrative comments included: “Wish I'd had this training earlier,” and “I really appreciate the perspective. I will try it out today.” Discussion Due to the success of this curriculum, it was discussed during a departmental Grand Rounds presentation and was made accessible to outside providers; we received requests from other institutions, who were enthusiastic about the mnemonic utilized in this resource, to present this approach to their own trainees.

Abstract This tool was created to address a perceived gap in the education of our postgraduate internal medicine trainees around the practical aspects of end-of-life decision making. Based on an extensive up-to-date literature review of the topic, the PowerPoint presentation outlines several facets of end-of-life decision making: (1) components of these decisions and generally accepted definitions, (2) factors affecting patients' decisions, (3) substitute decision-maker accuracy, (4) physician-level factors affecting decision making, and (5) implications for everyday practice. The presentation is intended to be a springboard for an interactive discussion of experiences with end-of-life decisions and is best suited to an audience that has some experience with these situations (e.g., medical or surgical residents, ICU fellows, etc.). The session is 2 hours in duration, with a 10-minute break in the middle. It is possible to reduce the session to just 1 hour, but this will potentially curtail some of the discussion, which is likely to be the most stimulating and highest-rated component of the session. This session is unique in that it provides a forum for discussion, as well as an overview of the current state of the art in the factors known to influence end-of-life decision making. It has been presented as a 1-hour round for medical residents and students in two Toronto teaching hospitals. Although not formally evaluated, it was anecdotally highly rated by trainees at all levels.