Table 1

’CODE’: a code status improvement framework

PhasesElements of successProposed interventionEvaluation approach/metric
(C) Choice—reduce complexity
  • Simplify and reduce the number of code status options.

  • Reframe resuscitation as an attempt at CPR rather than a procedure likely to restore life.

  • Replace ‘Do Not Resuscitate (DNR)’ with ‘Do Not Attempt Resuscitation (DNAR)’.

  • Simplify code status choices to three options: DNAR, DNAR/OK to Intubate; and Full Code.

  • Patient-reported understanding of resuscitation options.

  • Percentage of high-risk patients with resuscitation status as DNAR or DNAR/OK to Intubate.

  • Eliminate inconsistent code status options including ‘Full Code, Do Not Intubate’.

(O) Order—entry support
  • Standardised code status order entry.

  • Widely understood periprocedural resuscitation policies.

  • Code status reconciliation across clinical encounters.

  • Develop and implement procedural resuscitation orders that demand timed Full Code order expiration for procedural DNR reversals.

  • Include guideline-based code status recommendations to preprocedural checklists.

  • Implement EHR interruptive alerts to reconcile code status order discrepancies AND guide clinicians to perform serious illness conversation for high-risk patients.

  • Frequency of code status orders on hospital admission and periprocedurally resuscitation preference (compared with MOLST or documented SIC).

  • Frequency of periprocedural resuscitation status errors.

(D) Discuss—don’t delay
  • CSDs occur with a majority of high-risk patients in the outpatient setting with longitudinal providers.

  • Code status confirmed as soon as possible on hospital admission.

  • Add code status to EHR dashboards and implement decision support tools to guide clinicians to perform and document serious illness conversations in high-risk patients.

  • Eliminate ‘Presumed’ code status as a durable order on hospital admission.

  • Frequency of SIC documentation among high-risk patients.

  • Frequency of resuscitation status confirmed on hospital admission.

(E) Educate—the workforce
  •  Adopt a common framework for serious illness conversations across the organisation.

  •  Confident and informed clinicians leading serious illness and code status discussions.

  • Institutionalise a common serious illness conversation (SIC) framework using the serious illness conversation guide as key tool.

  • Percentage of SIC trained staff.

  • Clinician qualitative measure of confidence in conducting code status and SIC.

  • Develop and implement training for all and preferably VitalTalk simulation-based instruction for select staff (admitting physicians, bedside nurses in ICU, surgical and medical floors).

  • CPR, cardiopulmonary resuscitation; CSD, code status discussion; EHR, electronic health record; ICU, intensive care unit; MOLST, Medical Orders for Life-Sustaining Treatment.