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Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study
  1. Jason N Batten1,2,3,
  2. Jacob A Blythe3,
  3. Sarah Wieten3,
  4. Miriam Piven Cotler4,
  5. Joshua B Kayser5,6,7,
  6. Karin Porter-Williamson8,
  7. Stephanie Harman1,3,
  8. Elizabeth Dzeng9,
  9. David Magnus3
  1. 1Department of Medicine, Stanford University, Stanford, California, USA
  2. 2Department of Anesthesia, Stanford University, Stanford, California, USA
  3. 3Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
  4. 4Department of Health Sciences, California State University Northridge, Northridge, California, USA
  5. 5Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  6. 6Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  7. 7Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
  8. 8Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
  9. 9Department of Medicine, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to Dr Jason N Batten, Department of Medicine, Stanford University, Stanford, CA 94305-6104, USA; jbatten{at}


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

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  • 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.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • 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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