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CODE: a practical framework for advancing patient-centred code status discussions
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  1. Alec Petersen1,
  2. James A Tulsky2,3,4,
  3. Mallika Mendu4,5
  1. 1Internal Medicine Residency Program, Brigham and Women's Hospital, Boston, Massachusetts, USA
  2. 2Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
  3. 3Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hosptial, Boston, MA, United States
  4. 4Harvard Medical School, Boston, Massachusetts, USA
  5. 5Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Alec Petersen, Internal Medicine Residency Program, Brigham and Women's Hospital, Boston, MA 02115, USA; AWPETERSEN{at}BWH.HARVARD.EDU

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Introduction

Every patient admitted to the hospital, scheduled for a procedure or facing a life-limiting illness potentially confronts a decision about cardiopulmonary resuscitation (CPR). Despite their importance and frequency, resuscitation or code status discussions (CSD) are often not included in broader serious illness conversations (SIC) or ignored altogether.1 CSDs for patients with serious, life-limiting illness should be incorporated into comprehensive serious illness care delivery, which includes discussions about advance care planning and goals of care at every stage of illness; ideally, for most patients, this will occur early in the disease trajectory.1 Yet, even when conversations occur, health systems frequently do not capture code status in an accurate, retrievable, timely and consistent manner.2 Failing to understand, document and act on patients’ preferences may lead to harm, like other medical errors. Potential outcomes of ineffective CSDs include unwanted CPR or other invasive procedures, and avoidable disability and distress to patients and families.3

Barriers to successful SICs and CSDs have been well described. Clinicians leading conversations are often untrained discussing the topic, under time constraints and concerned about conflicting with longitudinal providers.4 Patients routinely do not receive clear resuscitation options at the appropriate literacy level and overestimate the chances of successful resuscitation.5 Systems lack formal CSD training programmes, poorly implement guidelines and underuse electronic decision support shown to improve CSD documentation.1

This viewpoint seeks to define evidence-based high-yield opportunities that address root causes of CSD failures. We have outlined these opportunities in our proposed ‘CODE’ framework: (1) reduce Choice Complexity leading to poorly understood options; (2) standardise code status Order Entry to reduce errors during care transitions and periprocedurally; (3) guide clinicians away from Delayed Discussions in both inpatient and outpatient settings; (4) eliminate Education Failures that handcuff capable clinicians who lack formalised training. Table 1 …

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