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Abstract
Background US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied.
Design and methods Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences.
Results The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital’s code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories.
Conclusions There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.
- medical emergency team
- hospital medicine
- critical care
- communication
- shared decision making
Data availability statement
Deidentified interview transcripts are not available as participants were informed during the consent process that they would not be shared in their entirety outside of the research team. However, additional short deidentified quotes are available on request. Records of policy documents and ordering menus are not available as hospitals did not agree to share this information with a broad audience.
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Introduction
US hospitals accredited by the Joint Commission are required to have a Do Not Resuscitate (DNR) policy in place. However, some hospitals provide code status options in addition to DNR and Full Code, such as Partial Code,1–3 Limited Aggressive Therapy,4 Do Not Intubate,5 6 DNR/Do Not Escalate,7 and DNR/Comfort Care.8 Physicians typically must place an order for the code status option using an ordering menu, usually either a paper form or a form in the electronic health record (EHR).
The few published descriptions of code status options suggest that there is a great deal of variation in the code status options hospitals provide and the format of ordering menus.9–15 The present study sought to characterise variation in the design of code status options and to create a systematic framework for understanding this variation. Such a framework might be used to design code status options or evaluate their function.
More broadly, code status options may be an important contributor to variability in end-of-life care. Hospitals are known to differ substantially in the treatment intensity provided to patients, especially at the end of life.15–21 Existing evidence suggests that this is explained, at least partly, by differences in institutional norms or culture.22–32 Code status orders are routinely placed by physicians during critical decision-making points at the end of life. Our study also sought to assess the potential impacts of code status options on communication and decision-making practices in these contexts.
Methods
We designed an exploratory multi-institutional qualitative study to assess variation in the design of code status options and its perceived impacts. To enhance the diversity of perspectives for our qualitative analysis, we formed a multidisciplinary research team that included hospitalists, intensivists, palliative care consultants, clinical ethicists, a sociologist and individuals with experience in the design of code status options. Since we aimed to understand and improve on the design of code status options, we adopted a pragmatist research paradigm33 and used constructivist methods drawn from grounded theory as this topic had not yet been empirically studied.34 Our study was approved by the Stanford University Institutional Review Board.
Data collection
In order to increase the transferability of our results,35 36 we used maximum variation purposive sampling37 to select hospitals and physicians for inclusion in the study. We selected hospitals for variation in several features: geographical location (western, eastern and central US), type of institution (academic, community and government) and the design of available code status options (ie, the number and names of options). Our team included at least one individual who had practised or trained at each hospital (an “institutional lead”). Institutional leads provided copies of all hospital policies that enumerated and/or defined available code status options and copies of the ordering menu(s) used by physicians to place code status orders, such as paper order forms or screenshots of menus in the EHR.
At each hospital, we recruited physicians for interviews since physicians both place and interpret code status orders, purposively sampling from three inpatient services (hospital medicine, critical care and palliative care consultation).38 We selected these services because they include primary team members and consultants who facilitate decision-making about code status. At academic institutions, we additionally sampled trainee physicians, as prior work found they are especially shaped by institutional culture and policies regarding resuscitation decisions.28 We designed an interview guide to assess how physicians understood and interacted with code status options, including questions about the meaning, purpose, advantages and limitations of all available code status options. The lead investigator conducted audio-recorded semi-structured interviews, by phone or in person, which lasted 60–120 min. The interview guide was iteratively refined in response to emergent themes as interviews progressed. Interviews were transcribed verbatim and de-identified prior to analysis.
Analysis
In our analysis, we triangulated38 39 across three data sources: code status policies, code status ordering menus and physician interviews. First, two investigators collaboratively reviewed all policies and ordering menus to extract the names and definitions of all code status options, as well as the content and format of the ordering menus. Using this information, we created summaries of the code status options available at each hospital. We verified each summary with the relevant institutional lead.
Second, we analysed transcripts inductively using conventional content analysis.40 After collaboratively drafting a codebook and iteratively testing and refining it using subsets of transcripts, three investigators coded all transcripts in triplicate with periodic meetings to discuss each code placed and to adjudicate to consensus. Throughout the coding process, we drafted and discussed theoretical memos to build analytical insights regarding the design of code status options and its impacts. The results described in this paper emerged from the processes of coding and drafting theoretical memos. During our analysis of the last third of interview transcripts, we did not obtain any novel theoretical insights regarding the design of code status options and its impacts, indicating that we had reached theoretical saturation.41
Third, we created a systematic framework for evaluating the design of code status options. To do this, two investigators independently generated a list of key design characteristics that emerged during the analytical process described earlier. The two investigators achieved consensus on the names and definitions of each design characteristic, which were further refined through multiple rounds of discussion that involved the entire investigative team. Using the final set of design characteristics, two investigators independently judged whether each characteristic was present or absent for each hospital. Initial inter-rater reliability for these judgements was excellent (raw agreement=98%), and all disagreements were adjudicated to consensus. Consensus judgements were verified with institutional leads.
Results
We selected seven hospitals for inclusion, whose institutional characteristics are shown in table 1. At each hospital, we collected one to four policy documents and one to six records of ordering menus. At each hospital, three to six physicians participated (n=30), whose demographic characteristics are shown in table 1. The distribution of our demographic variables indicated that we achieved the purposive sampling goals outlined earlier. Physician participants had worked at the hospital under study for a median of six years.
Characteristics of selected hospitals and physician participants
We used policy documents and ordering menus to describe the available code status options at each hospital (table 2). One hospital had recently changed its code status options; we collected all data for both sets of code status options at this hospital, yielding a total of eight sets of code status options included in the study. These two sets of code status options from the same hospital are indicated with an asterisk in all relevant tables.
Available code status options at selected hospitals
Available code status options at selected hospitals
Each hospital provided a distinct set of code status options (table 2). The number of code status options ranged from two to five. The code status options varied widely in their names and policy definitions; other than Full Code, which was present at several institutions, no other code status option was present in identical form at more than one institution. DNR orders were named and defined differently at each hospital studied. Some hospitals provided a single DNR order, while other hospitals provided two or three DNR orders. With regard to ordering menus, each hospital used menus, checkboxes and free-text boxes in different manners.
Key design characteristics of code status options
We identified five key characteristics in the design of code status options. These characteristics were not apparent at the time of institutional selection, but rather were inductively identified through our analytical process. Each characteristic is “key” in the sense that it impacts which aspects of clinical care a physician is able to influence by placing a code status order. Thus, the key design characteristics describe the function of the set of code status options at each hospital. Each characteristic is defined and illustrated with examples and physician quotations in table 3. Each characteristic is described in the following text.
Framework of key characteristics in the design of code status options
1. Allows partial codes
Some hospitals provided a code status option that allowed specific components of resuscitation to be withheld. Participants tended to report that these options were used to selectively withhold either cardiac resuscitation or intubation. For example, a physician might place a Partial Code order to prevent resuscitation in the event of cardiac arrest, but otherwise allow intubation. Some hospitals used code status options that provided a greater degree of specificity, allowing physicians to selectively withhold chest compressions, defibrillation, bag mask ventilation and so on. Many participants expressed concern that allowing physicians to withhold specific components of resuscitation might lead to combinations of interventions that do not “make clinical sense,” such as initiating resuscitation for a cardiac arrest but withholding intubation after return of spontaneous circulation. These participants stated that resuscitation during a cardiac arrest is “all-or-nothing” and “black-and-white,” conveying that resuscitation should not be fragmented. However, at hospitals that allowed partial codes, some physicians appeared to accept or even defend this fragmentation, sometimes accepting any combination of interventions requested by a patient or surrogate decision-maker.
2. Distinguishes intra-arrest and extra-arrest treatment
Many participants felt that components of resuscitation during cardiac arrest also had indications outside of cardiac arrest. For example, intubation can be performed during cardiac arrest as part of standard resuscitative efforts or can be performed outside of cardiac arrest to treat a reversible pulmonary issue. Similarly, while defibrillation can be performed during cardiac arrest as part of standard resuscitative efforts, electrical cardioversion more generally (“shocks”) can be performed outside of a cardiac arrest to treat a tachyarrhythmia. Some hospitals provided code status options that distinguished between withholding such interventions during cardiac arrest and withholding them outside of cardiac arrest. At hospitals whose code status options did not make such a distinction, participants sometimes stated that this lack of clarity led to “confusion” among the clinical team, with some identifying it as a “safety concern.”
3. Addresses life-sustaining treatments
Some hospitals provided ordering menus, such as checkboxes, which allowed physicians to withhold pre-specified interventions outside of cardiac arrest. These addressed a variety of life-sustaining treatments including vasopressors, intubation and mechanical ventilation, noninvasive positive pressure ventilation, dialysis, blood product transfusions, artificial nutrition and hydration, and antibiotics. Across hospitals, participants felt it was important to clarify the acceptability of life-sustaining treatments to prevent unwanted escalations of care prior to cardiac arrest. If hospitals did not provide ordering menus to do this, participants reported either clarifying through alternative means, such as a goals of care note, or they made inferences about these life-sustaining treatments from the patient’s code status.
4. Addresses transfer to higher-acuity units
Some hospitals provided code status options that allowed physicians to prevent transfer to a higher-acuity unit, such as the intensive care unit (ICU). Most physicians felt it was important to clarify the acceptability of transfer to the ICU, especially in the setting of a rapid response team or code blue. If hospitals did not provide ordering menus to do this, participants reported either clarifying through alternative means, such as a handoff form, or they made inferences about the acceptability of ICU transfer from the patient’s code status.
5. Addresses philosophy of treatment
At some hospitals, code status options included treatment-guiding philosophies of care, such as “no escalation of treatment” or “comfort measures only.” In most cases, a DNR order was combined with a treatment-guiding philosophy in order to form a single code status order (eg, a DNR/Do Not Escalate order, a DNR/Comfort Measures Only order). These code status options required some degree of clinical interpretation about whether a clinical action was compatible with the stated philosophy. For example, several participants questioned whether providing intravenous antibiotics was compatible with a DNR/Comfort Measures Only order. While some participants felt these code status options were “ambiguous,” others felt that code status options that included treatment-guiding philosophies of care provided a greater sense of the patient’s overall clinical trajectory.
Variation in key design characteristics across hospitals
Each key design characteristic was present at some hospitals but not at others. When we compared all of the hospitals in our sample, we found that each hospital’s code status options were unique with respect to which key design characteristics were present or absent (table 4). Thus, code status appeared to play a different role in each institution. For example, at certain institutions (eg, hospital A), code status appeared to guide care only during a cardiac arrest. At other institutions (eg, hospital H), code status appeared to guide care in a number of other domains, including the use of life-sustaining treatments, transfer to higher-acuity units and communication of a philosophy of care.
Variation in the presence of key design characteristics across hospitals
Perceived impacts of the design of code status options
Across hospitals, participants perceived that the design of code status options impacts clinical care by shaping communication and decision-making practices. Participants observed these impacts in the context of decisions about resuscitation and life-sustaining treatments, especially at the end of life. Overall, participants had mixed opinions of whether these impacts were desirable or not.
We identified four potential mechanisms (table 5), through which a hospital’s code status options might influence communication or decision-making practices.
Potential mechanisms through which the design of code status options shapes communication and decision-making practices
Framing conversations: The design of code status options might influence how physicians frame conversations with patients or their surrogate decision-makers. For example, many participants observed that some physicians would present code status options in a rote fashion as a menu from which patients could select.
Prompting decisions: The design of code status options might prompt physicians to think through or discuss particular clinical decision points. For example, at hospitals whose code status options addressed whether a patient could be transferred to the ICU, physicians reported determining the acceptability of ICU transfer at the point of code status order placement, even if this otherwise might not have been considered.
Shaping inferences: The design of code status options might determine what information is explicitly available in a code status order, and thus, what information might be inferred. Depending on the design of the code status options, participants reported making a broad array of inferences from a patient’s code status order, including inferences about the patient’s overall clinical trajectory, the patient’s preferences or goals of care, whether a patient should be offered a particular clinical intervention or whether a patient had engaged in advance care planning.
Creating categories: The design of code status options might shape the mental map that physicians use to sort patient cases into clinically meaningful groups. Many participants spoke of the code status options at their hospital as “categories,” “buckets” or a “theoretical framework” that is used to guide clinical decisions in emergency or other end-of-life situations. Some participants articulated that certain clinical strategies, such as adopting a “no escalation of treatment” strategy, were more likely to be used by physicians when they were explicitly available as code status options. Similarly, some participants articulated that these strategies were less likely to be used if they were not codified as an explicit code status option.
Discussion
In this exploratory qualitative study, we used policy documents, records of ordering menus and physician interviews to characterise eight sets of code status options from a varied sample of US hospitals. Using inductive qualitative methods, we identified key design characteristics in the design of code status options and elucidated potential impacts of these design differences. There are several notable results from our study.
First, while existing literature on code status tends to view DNR orders as independent entities,42 43 our study draws attention to the fact that US hospitals provide sets of code status options. These sets include DNR orders but also include a variety of other code status options (table 2). We found a high degree of variability across hospitals in the design of code status option sets. Hospitals differ in the number of code status options provided, as well as their names, definitions and associated ordering menus. The nature and extent of variation in the design of code status options has not been characterised previously, although prior studies have demonstrated variation in other aspects of code status policies (eg, processes for obtaining and documenting informed consent).44–47
Second, although guidelines typically view DNR orders as having consistent meanings across institutional settings, we found that DNR orders were named and defined differently at each hospital in our sample. This has implications for research that quantitatively examines the impact of DNR orders across hospitals.16 20 21 For example, a DNR order that also conveys a “comfort measures only” philosophy of care (eg, a DNR/Comfort order at hospital G) is likely to have a different impact on clinical care than a DNR order that only specifies that resuscitation should not be attempted in the event of cardiac arrest (eg, a No Code order at hospital A). Future research in these areas will need to account for variability in the design of DNR orders when comparing their effects across hospitals.
Third, our study identified five key design characteristics that impact which aspects of clinical care a physician is able to influence by placing a code status order. These characteristics are variably present or absent among the eight sets of code status options studied. These characteristics were not apparent at the time of institutional selection, but rather were inductively identified through our analytical process. Our framework of key design characteristics can be used by individuals interested in designing or evaluating code status options. Each characteristic represents an important decision point in the design of any set of code status options because it affects the function of a code status order.
Fourth, we found each hospital’s code status options were unique with respect to the five key design characteristics, indicating that code status plays a different role in each of the hospitals studied. Historically, DNR orders have been defined in US guidelines as guiding care only during cardiac arrest.48 49 Nevertheless, prior work has shown that DNR orders, even when they are understood in this narrow sense, influence care outside of cardiac arrest.50–53 Our study found that some hospitals provide code status options that are explicitly designed to guide care in a number of domains outside of cardiac arrest, including the use of life-sustaining treatments, transfer to higher-acuity units and communication of a philosophy of care (tables 3 and 4). Recent medical literature calls for a transition away from narrow DNR orders towards broader plans for responding to clinical decompensations, even prior to cardiac arrest.54–57 This transition is manifested in the widespread adoption of Physician Orders for Life Sustaining Treatment forms in the US58 and the adoption of emergency care plans in the UK.59–65 Our results illustrate that in-hospital code status orders are also reflective of this ongoing transition. At some hospitals, code status has remained narrowly focused on cardiac arrest while at other hospitals, code status guides care more broadly (table 4). While our study has documented this variation among hospitals, it was not designed to assess which approach to the design of code status is preferable. Future work is needed to determine the appropriate role of code status orders in the inpatient setting.
Fifth, we found that the design of a hospital’s code status options may shape communication and decision-making practices, especially at the end of life. Choice architecture theory66 67 may provide some degree of insight into these effects. It describes how the structure of a choice, even the choice among code status options, may have effects on subsequent decision-making processes.
However, our study does not allow us to tease apart the directionality of causation between the design of code status options and communication and decision-making practices. It is possible, for example, that code status options are reflective of pre-existing practices. This hypothesis aligns with values-sensitive design, an approach to design that explicitly considers how pre-existing values can be embodied in technical systems and devices, such as code status ordering menus.68 69 It seems likely that there is a complex interplay between the code status options at a particular hospital and its unique communication and decision-making practices. Individuals interested in designing hospital code status options should be aware that code status options may further instantiate existing practices, or alternatively, shape the formation of new practices. In addition, these individuals should consider potential impacts of code status options that operate through the four mechanisms we identified: framing conversations, prompting decisions, shaping inferences and creating categories.
Of particular interest is whether the design of code status options can explain, at least partially, the variability in end-of-life care and treatment intensity observed across US hospitals.15–21 It is possible that the design of code status options, which frame many end-of-life decisions, may be associated with institutional norms and patterns in end-of-life care, ultimately shaping overall treatment intensity. A growing body of work in the last two decades has examined organisational determinants of treatment intensity.22–32 One prior study23 found that the presence of a formal code status policy did not contribute to observed differences in end-of-life treatment intensity. However, this study did not account for the high degree of variability in the design of code status options found in our study.
It remains an open question whether hospitals can proactively design code status options to intentionally shape institutional norms and patterns in end-of-life care. Little is known about how US hospitals design code status options. At least one state, Ohio, mandates that all hospitals use the same code status options.70–72 Otherwise, to our knowledge, US hospitals (or hospital networks) are generally free to design their own code status options. Our anecdotal experience suggests that hospitals use differing processes and involve differing sets of stakeholders when designing code status options. The lack of standardisation is likely a contributor to the variation observed in our study. Future work is needed to better understand how hospitals design code status options and how this process can be optimised.
In addition to the limitations described earlier, our study faces several additional limitations which should be addressed in future work. First, our study characterised variation in the design of code status options but did not assess the prevalence of design characteristics outside of our small sample of US hospitals. Second, our study assessed the perceived impacts of the design of code status options but did not link design differences to observed differences in communication, decision-making, clinical outcomes or overall treatment intensity. Third, our study included physicians who place and interpret code status orders but did not include the entire range of healthcare providers who interact with code status options.
Conclusions
There are substantive differences in the design of hospital code status options which may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.
Data availability statement
Deidentified interview transcripts are not available as participants were informed during the consent process that they would not be shared in their entirety outside of the research team. However, additional short deidentified quotes are available on request. Records of policy documents and ordering menus are not available as hospitals did not agree to share this information with a broad audience.
Ethics statements
Acknowledgments
First and foremost, we thank the physician participants who generously contributed their time to this study. We also thank: Katherine Kruse MD for intellectual and administrative contributions to an earlier version of this study; Emmy Shearer MPP MSc and Mildred Cho PhD for assistance in framing the research findings of this study; and Karen Jarnagin MPH for assistance in editing the manuscript.
References
Footnotes
Funding Jason N Batten’s time was funded by the Stanford Medical Scholars Fellowship Program (#30521) and by a T32 grant (T32HG008953, The Stanford Training Program in Ethical, Legal, and Social Implications Research) from the National Human Genome Research Institute. Jacob A Blythe’s time was funded by the Stanford Medical Scholars Fellowship Program (#30879).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.