Ethical Dilemma in the nursing field

Timing of code status documentation and end-of-life outcomes in patients admitted to an oncology ward
Amanda Caissie & Nanor Kevork & Breffni Hannon & Lisa W. Le & Camilla Zimmermann
4 June 2013 /Accepted: 11 September 2013 /Published online: 28 September 2013 # Springer-Verlag Berlin Heidelberg 2013
Abstract Purpose Guidelines recommend documentation of care pref- erences for patients with advanced cancer upon hospital ad- mission. We assessed end-of-life outcomes for patients who did or did not have code status (CS) documented within 48 h of admission. Methods This was a retrospective cohort study of patients who died on an inpatient oncology ward between January 2004 and February 2009. Primary end-of-life outcomes were “code blues” and cardiopulmonary resuscitation (CPR) at- tempts; secondary outcomes included unsuccessful CPR at- tempts, intensive care unit (ICU), consultations, and ICU admissions. Using logistic regression, outcomes were com- pared between those with and without CS documentation ?
48 h from admission (full code or do-not-resuscitate), con- trolling for significant confounders.
Results The 336 patients had a median age of 61 years; 97 % had advanced cancer. The median time from admission to death was 12 days (range <1–197 days); 151 patients (45 %) had CS documentation ?48 h from admission. Controlling for confounders of reason for admission and marital status, pa- tients with CS documentation ?48 h from admission had fewer “code blues” (2 vs. 15 %; adjusted odds ratio (AOR) 0.12, 95 % confidence interval (CI) 0.02–0.43), CPR attempts (1 vs. 11 %; AOR 0.12, 95 % CI 0.01–0.51), unsuccessful CPR attempts (0 vs. 11 %), ICU consultations (9 vs. 30 %; AOR 0.19, 95 % CI 0.08–0.40) and ICU admissions (2 vs. 5 %; AOR 0.18, 95 %CI 0.02–0.85). Conclusions In patients who died on an oncology ward, CS documentation within 48 h of admission was associated with less aggressive end-of-life care, regardless of the reason for admission.
Keywords Cancer . Code status . Intensive care unit .
Cardiopulmonary resuscitation . Advance directives
When first introduced around 1960, cardiopulmonary resus- citation (CPR) was used mainly intra-operatively[1].
In the 1970s, The American Medical Association recommended documentation of code status in the hospital chart, and hospi- tal policies made CPR the default unless do-not-resuscitate (DNR) orders were written
Decades later, this policy remains in place, yet there are low rates of code status docu- mentation in hospitalized patients [3–5] Such documentation is important, given the low rates of CPR success in hospital inpatients. Although approximately 4 out of 10 patients have a return of spontaneous circulation, only 10–20 % survives to hospital discharge [6, 7].
A. Caissie Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada
B. Hannon :C. Zimmermann Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, Canada
N. Kevork : B. Hannon :C. Zimmermann (*) Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, Toronto, University Health Network, 610 University Ave., 16-712, M5G 2M9 Toronto, ON,
C. Zimmermann Campbell Family Cancer Research Institute, Ontario Cancer Institute, Princess Margaret Hospital, Toronto, University Health Network, Toronto, Canada
L. W. Le Department of Biostatistics, Princess Margaret Hospital, Toronto, University Health Network, Toronto, Canada

The success rate of CPR is even lower in patients with cancer, and is further reduced by metastatic disease, poor performance status, advanced age, and acute illnesses includ- ing infection [6, 8, 9]. A meta-analysis of 42 studies from 1966 to 2005, specifically in hospitalized patients with cancer, reported an overall survival rate to discharge of 6.2 % (9.5 % in patients with localized disease and 5.6 % in patients with metastatic disease) [9].
For patients whose cardiac arrest was anticipated, rather than occurring unexpectedly, the survival rate to discharge after CPR was 0 % [8].
Due to these exceedingly low rates of success for CPR in hospitalized patients with cancer, guidelines recommend that for patients with advanced cancer, goals of care should be reviewed and documented within 48 h of any admission to a hospital [10].
While the latter publication does not explicitly define advanced cancer, it has been defined elsewhere as cancer that is incurable [11].
These recommendations for goals of care discussions are in line with the Patient Self Determination Act, which requires that all institutions in the USA that are receiving Medicare/Medicaid funds inform pa- tients, upon admission, of their right to accept or refuse treatment and their right to an advance directive, regardless of whether or not their cancer is in the advanced stages [12].
However, the guideline of documenting goals of care within 48 h is founded only from level III evidence (textbooks, opinions, and descriptive studies) [10].
Scant evidence exists regarding both the frequency with which code status is actu- ally documented within 48 h of admission, and whether this serves to reduce aggressive end-of-life care [13].
Early code status documentation may decrease the number of patients subjected to aggressive interventions not appropri- ately aligned with goals of care. The aims of the current study were(1) to assess the timing of code status documentation in all patients who died after admission to an oncology ward and (2) to examine whether code status documentation within 48 h was associated with less aggressive end-of-life care. We hypothe- sized that code status documentation within 48 h would be associated with fewer “code blues” and CPR attempts. Second- ary outcomes included unsuccessful CPR attempts and inten- sive care unit (ICU) consultations and admissions before death.
Materials and methods
Study site and sample
The study took place at Princess Margaret Hospital (PMH), a comprehensive cancer center and member of the University Health Network (UHN) in Toronto, Canada. In addition to PMH, the UHN also includes two general hospitals: Toronto General Hospital and Toronto Western Hospital. The study sample included consecutive inpatients that died between Janu- ary 2004 and February 2009, inclusive, on the two general
oncology (medical or radiation oncology) wards at PMH, which have a total of 40 beds. Patients admitted to these wards all have solid tumors, with the exception of a small minority of patients with lymphoma or multiple myeloma who are admitted for palliative radiation. PMH also has 69 beds allocated for patients with hematologic malignancies and a 12-bed palliative care unit (PCU); patients who died on these units were not included in the study. PMH has no emergency department; however, patients have access to the emergency departments of the other UHN hospitals. Patients may be admitted either directly from ambula- tory care; transferred from general medical or surgical wards at another hospital; or transferred after presenting at the emergency department at another hospital.While PMH has no ICU, patients have access to ICU care at the adjacentMount Sinai Hospital via a bridge connecting the two hospitals.
This research was conducted following approval of the UHN Research Ethics Board. Two investigators (AC and NK) conducted a thorough retrospective chart review, using a standardized abstraction spreadsheet. Data abstracted included information on patient demographics, cancer diagnosis and stage, admission date, reason for admission, admitting service, status of the physician admitting the patient (patients may be admitted onto the service of a staff physician by this physician personally or by a hospitalist, fellow, or resident), code status documentation, ICU consultations and admissions, CPR at- tempts (and outcome thereof), and date and cause of death.
Data collection was facilitated by the availability of data- bases and standardized forms. The reason for admission is specified by the admitting physician at the time that the patient is placed on the waiting list for admission, and is then entered into the standardized database by the admissions coordinator (a registered nurse) using a drop-down menu of different potential reasons for admission. When there are multiple reasons for admission, the primary reason is recorded. For this study, the 28 reasons for admission listed in the database were grouped into three categories: symptom control, cancer treat- ment or investigation, and palliative planning (Table 1). The last category was taken unaltered from the database, and refers to patients whose condition is deteriorating at home, and who are admitted with the anticipation of transfer to hospice or PCU or discharge home with further support.
Code status documentation and ICU consultations and admissions were abstracted from the physician’s orders and from the chart notes. Code status documentation was taken from the inpatient medical orders, because according to UHN policy, this is where DNR documentation must be, to be followed for inpatients. Code status was classified as “full code” or “DNR”. A DNR order precludes the interventions of chest compressions, defibrillation, or intubation in the event of a cardiopulmonary arrest, but does not preclude an ICU consultation or admission. Details of code blues and CPR attempts and outcomes were abstracted from standardized forms completed by the code blue team.
The date and cause of death was obtained from the death certificate, a copy of which was included in each chart.
A “code blue” was defined as any medical emergency where there was documented involvement of the code blue team (cardiopulmonary arrest or near-cardiopulmonary ar- rest). CPR attempts were defined as instances where there were documented attempts at resuscitation, including chest compressions, defibrillation, and/or intubation. CPR was de- fined as “successful” if the patient was revived and survived for one or more days and “unsuccessful” if the patient was not revived or survived for less than 1 day. All ICU admissions at PMH are preceded by an ICU consultation, but an ICU consultation does not necessarily result in an admission to the ICU. All code blues result in an ICU consultation; in addition, the ICU staff may provide consultations on the PMH oncology wards for medical emergencies that have not yet progressed to the severity of a code blue. ICU consulta- tions may also be requested pre-emptively, to provide input regarding whether or not CPR and ICU admission would be appropriate for a particular patient. These pre-emptive consul- tations are rare and supplement rather than replace the more usual situation of a code status discussion with the primary oncologist, admitting oncology team, or palliative care team.
A UHN policy is in place to guide the medical team through decision making with respect to life support interventions and code status discussions. During the study period, there was no institutional policy or guideline regarding the actual timing of such code status discussions, nor is there one currently.
Statistical analysis
Associations between timing of initial code status documen- tation (?48 h from admission, vs. longer or not at all) and patient characteristics were assessed using chi-square, Fisher’s exact, and t tests, as appropriate. Associations between timing of code status documentation and end-of-life outcomes (code blue, CPR attempt, unsuccessful CPR attempt, ICU consulta- tion, ICU admission) were then assessed using multivariable logistic regression analyses, adjusting for significant con- founders. Confounders were defined as patient characteristics associated with both timing of code status documentation and any end-of-life outcome (p <0.05). Marital status and reason for admission met criteria as confounders and were included in the multivariable analysis. Among the reasons for admis- sion, inclusion of “palliative planning” caused separation of the data, because a large majority of patients admitted for palliative planning also had code status assessed within 48 h of admission.
Therefore, patients admitted for palliative plan- ning were excluded from the multivariable analysis.
Table 2 shows the timing of relevant end-of-life events for the 336 patients who died on the oncology wards during the study period. Of 336 patients, only 151 (45 %) had code status documentation ?48 h from admission (141 as DNR and 10 as full code) and 28 (8 %) had no documentation of their code status before death. Of note, 16 patients had a change in their code status: for 12 patients (whom had code status documen- tation within 48 h), an initial “full code” status was subse- quently changed to DNR; for 4 patients, (whom had code status documentation within 48 h) an initial DNR status was changed to full code, and then back to DNR prior to death. Twenty-eight patients died within 48 h of admission; 23/28 had code status documented, and 5/28 did not. Of the 23 who did have code status documented, one (documented as full
Table 2 End-of-life milestones
End-of-life events All patientsa
Code status documented before death 308 (92)
Code status documentation within 48 h of admission 151 (45)
Code status documentation within 48 h of death 88 (26)
Time from admission to death; median (range), in days 12 (1–197)
Time from admission to initial documentation of code statusb; median (range), in days
3 (1–178)
Time from initial code status documentation to deathb; median (range), in days
6 (1–97)
Time from initial code status to final code statusc; median (range), in days
3 (1–39)
Time from final code status to deathc; median (range), in days
6 (1–34)
a Unless specified, units for all characteristics are number (%), and n =336 b n=308 patients who had their code status documented c n=16 patients who had a change in code status
Table 1 Categories of reasons for admission listed in oncology database
Category Reasons for admission listed in oncology database
Symptom control Pain control, dehydration, neurological changes, biochemical abnormality, hematological abnormality, bleeding, bowel obstruction, nausea/vomiting, distal vein thrombosis/ pulmonary embolus, superior vena cava obstruction, seizures, hypercalcemia, fever not yet diagnosed, off-treatment deterioration, febrile neutropenia, infection, pleural effusion, respiratory problems, other medical problem
Cancer treatment or investigation
Radiation therapy, radiation chemotherapy, chemotherapy, investigation, cord compression, staging, gastrostomy tube, on- treatment deterioration
Palliative planning Palliative planning
Support Care Cancer (2014) 22:375–381 377
code) was transferred to the ICU after a code blue and success- ful CPR. Of the five who did not have code status documented, all had unsuccessful CPR after a code blue. All of these patients had advanced illness and deteriorating status on admission.
The demographics of all 336 patients are presented in Table 3, both for the entire study population and according to timing of code status documentation. Of all patients, (295/336) had stage IV disease on admission; of those with non-stage IV disease, all but 10 (3 % of the whole sample) had advanced, incurable disease at admission (for example advanced glioblastoma). Ninety-six percent died of their cancer, with the remaining 13 patients dying either from complications of the disease or from severe medical comorbidities. Code status documentation ?48 h after admission was associated with being married and admis- sion for palliative planning and negatively associated with ad- mission for cancer treatment or investigation. Specifically, 29/34 (85 %) of patients admitted for palliative planning, 87/195 (45 %) admitted for symptom control, and 35/107 (33 %) of patients admitted for cancer treatment or investigation, had code status documentation within 48 h.
After excluding the 34 patients who were admitted for palliative planning, and adjusting for other reason for admis- sion and marital status, patients with code status documenta- tion ?48 h from admission had significantly fewer code blues, CPR attempts, and ICU consultations and admis- sions (Table 4). All 20 CPR attempts in the group that did not have code status documented within 48 h after admission were unsuccessful (for 18 attempts the patient was not revived; for 2, the patient survived less than 24 h), whereas the 2 in the ?48 group (both “full code” documentations) were successful in reviving the patient. In both of these cases with successful CPR attempts, the patient’s code status was changed to DNR upon transfer back to the oncology ward (3 to 11 days post- CPR), and cancer-related death occurred within 3 weeks of initial resuscitation.
We repeated the analyses discounting the patients who died within 48 h of admission, and the results remained significant for all outcomes (p <0.05).
Current recommendations for patients with advanced cancer are to discuss and document goals and preferences for care within 48 h of admission to hospital [10]. This 48-h window allows for appropriate code status documentation, while leav- ing time for the oncology team to gather information that may aid in the discussion, including the input of the primary treating oncologist. The results of our study support documen- tation of code status within this time frame.
The large majority of patients who died on the inpatient oncology service during the 5-year study period had incurable cancer. Although code status was documented in more than
90 % before they died, documentation was completed within 48 h of admission in only 45 % of the overall sample, and did not take place consistently even in patients admitted for pal- liative planning. In those patients who had code status docu- mented within 48 h, there was less aggressive end-of-life care for all measured outcomes, even after adjusting for confound- ing variables of reason for admission and marital status.
Other studies have demonstrated the effect of end-of-life discussions on less aggressive medical care near death, dem- onstrating lower rates of ventilation, resuscitation, and ICU admissions [14, 15].
In a recent study of patients with ad- vanced lung or colorectal cancer, those who had end-of-life discussions before the last 30 days of life were less likely to receive aggressive measures at the end-of-life, including che- motherapy and acute hospital-based care [16].
As well, in a retrospective study of 118 terminally ill oncology inpatients, earlier recognition that the patient was dying was associated with timelier establishment of goals of care, including earlier DNR code status documentation and discontinuation of anti- cancer therapy [13].
Our study adds to this body of literature encouraging appropriate discussion of end-of-life planning, by specifically supporting the documentation of code status in patients with advanced cancer within 48 h of hospital admission.
It is increasingly accepted that aggressive end-of-life care for patients with advanced cancer is not only cost-ineffective but also represents poor quality care [17–20]. CPR is a highly costly intervention [21],
and the very small chance that pa- tients with advanced cancer have of surviving to discharge after a cardiopulmonary arrest [9]
approaches zero when the arrest is anticipated [8].
In the current study, 11 % of those who had their code status documented greater than 48 h after admission died after an unsuccessful CPR attempt, compared to none in the ?48 h group. This is an unpleasant way to die and can have adverse effects for all involved. Aggressive care in the final week of life has been associated with poor patient quality of life, as well as with a higher risk ofmajor depression in bereaved caregivers [15].
Unsuccessful CPR attempts are also highly disturbing for those performing it; generally, phy- sicians in training [22].
Code status discussions are complex and challenging, and physicians may feel reluctant to discuss such a sensi- tive topic [23]. Patients generally have a poor understand- ing of CPR and its low success rate in patients with advanced illnesses [24] and this is important to convey in a clear and sensitive manner [25].
Evidence suggests that patients are receptive to discussions about code status and other advance directives on admission to hospital [26, 27], and that code status discussions at admission do not affect patient or surrogate satisfaction with care [28].
Indeed, having a DNR order at the time of death has been associ- ated with higher quality of end-of-life care ratings by family members [29].
Ideally, these discussions take place

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