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Cited by 33Palliative Care and End-of-Life IssuesPalliative and Oncologic CareEthics and bioethics in healthcare

Processes of code status transitions in hospitalized patients with advanced cancer

Open access
El‐Jawahri, Areej, Lau‐Min, Kelsey, Nipp, Ryan D., Greer, Joseph A, Traeger, Lara N., Moran, Samantha M., D'Arpino, Sara M., Hochberg, Ephraim P. +5 more·2017·Cancer
DOI 10.1002/cncr.30969PMC PMC5716901
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Abstract

BACKGROUND: Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown. METHODS: We conducted a mixed‐methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus‐driven medical record review to characterize processes that led to code status order transitions from full code to DNR. RESULTS: In total, 1047 hospitalizations were reviewed among 728 patients. Admitting clinicians did not address code status in 53% of hospitalizations, resulting in code status orders of “presumed full.” In total, 275 patients (26.3%) transitioned from full code to DNR, and 48.7% (134 of 275 patients) of those had an order of “presumed full” at admission; however, upon further clarification, the patients expressed that they had wished to be DNR before the hospitalization. We identified 3 additional processes leading to order transition from full code to DNR acute clinical deterioration (15.3%), discontinuation of cancer‐directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared with discontinuing therapy and education, transitions because of acute clinical deterioration were associated with less patient involvement (P = .002), a shorter time to death (P < .001), and a greater likelihood of inpatient death (P = .005). CONCLUSIONS: One‐half of code status order changes among hospitalized patients with advanced cancer were because of full code orders in patients who had a preference for DNR before hospitalization. Transitions due of acute clinical deterioration were associated with less patient engagement and a higher likelihood of inpatient death. Cancer 2017;123:4895‐902. © 2017 American Cancer Society.

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  • Prior work suggests that discussing code status early in admission may relate to preference changes, with many patients moving from full code to DNR.

    “Some studies have suggested that early code status discussions during hospital admission may be associated with changes in patient preferences, with a significant proportion switching from full code to DNR. 12”

    From In-Hospital Code Status Updates: Trends Over Time and the Impact of COVID-19 (2024) · cites this paper as [12]

    The Results report that 26.3% of patients transitioned from full-code to DNR orders during hospitalization. But 48.7% of those patients already preferred DNR before admission, so their order changes did not represent changes in preference. The Discussion recommends prompt admission discussions; it does not establish that early discussions were associated with preference changes. (LLM, conf=0.88)

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  1. [3]Institute_of_Medicine Crossing the quality chasm Washington, DC National Academy Press 2003

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Authors
El‐Jawahri, A., Lau‐Min, K., Nipp, R. D., Greer, J. A., Traeger, L. N., Moran, S. M., D'Arpino, S. M., Hochberg, E. P., Jackson, V. A., Cashavelly, B. J., Martinson, H. S., Ryan, D. P., & Temel, J. S.
Affiliations
  • Department of Medicine Massachusetts General Hospital Boston Massachusetts
  • Harvard University (US)
  • Massachusetts General Hospital (US)
ORCID
Venue
Cancer
Publisher
Wiley
Published
2017-09-07
Volume
123
Issue
24
Pages
4895-4902
ISSN
  • 0008-543X (ISSN-L)
  • 1097-0142
DOI
10.1002/cncr.30969
PMC
PMC5716901
OpenAlex
W2753257903
Cited by
33
References
29
Citations by year
2026: 1 · 2025: 3 · 2024: 3 · 2023: 3 · 2022: 4 · 2021: 3 · 2020: 8 · 2019: 5 · 2018: 2
FWCI
3.85
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Cancer (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Cancer Institute
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
Keywords
code status, do-not-resuscitate orders, advanced cancer, hospitalized patients, patient preferences, patient engagement, inpatient deaths, cardiopulmonary resuscitation
MeSH terms
Aged, Aged, 80 and over, Cause of Death, Female, Hospitalization, Humans, Male, Massachusetts, Middle Aged, Neoplasm Invasiveness, Neoplasms, Prospective Studies, Terminal Care, Cohort Studies, Resuscitation Orders, Cardiopulmonary Resuscitation, Hospital Mortality, Risk Assessment, Needs Assessment

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