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Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study
Open accessAbstract
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.
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Substantive differences in the design of hospital code status options may contribute to known variability in end-of-life care and treatment intensity among USA hospitals.
“It is recognised that 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 USA hospitals66”
From Do not attempt cardiopulmonary resuscitation decision-making process: scoping review (2025) · cites this paper as [66]
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Federico, C. A., Heagerty, P. J., Lantos, J., O'Rourke, P., Rahimzadeh, V., Sugarman, J., Weinfurt, K., Wendler, D., Wilfond, B. S., & Magnus, D. (2022) · Contemporary Clinical Trials · doi:10.1016/j.cct.2022.106703 · Cited by 11
Do not attempt cardiopulmonary resuscitation decision-making process: scoping review
Doody, O., Davidson, H., & Lombard, J. (2025) · BMJ Supportive & Palliative Care · doi:10.1136/spcare-2023-004573 · Cited by 10
“…design of hospital code status options which may contribute to known variability in end- of-life care and treatment intensity among USA hospitals 66 and data supports the idea that Qualitative & mixed methods clinicians followed the recommendations to initiate treatment limitation conversations.”
Metadata
- Authors
- Batten, J. N., Blythe, J. A., Wieten, S., Cotler, M. P., Kayser, J. B., Porter-Williamson, K., Harman, S., Dzeng, E., & Magnus, D.
- Affiliations
- Stanford Medicine (US)
- California State University, Northridge (US)
- Philadelphia VA Medical Center (US)
- University of Kansas (US)
- University of California, San Francisco (US)
- Corresponding author
- Batten, Jason N
- Venue
- BMJ Quality & Safety
- Publisher
- BMJ
- Published
- 2020-10-20
- Volume
- 30
- Issue
- 8
- Pages
- 668-677
- ISSN
- 1475-3898 (ISSN-L)
- 2044-5415
- 2044-5423
- OpenAlex
- W3093858862
- Cited by
- 19
- References
- 5
- Citations by year
- 2026: 2 · 2025: 4 · 2024: 7 · 2023: 3 · 2022: 3
- FWCI
- 1.13
- Type
- journal article
- Language
- en
- Open access
- Licence
- cc-by
- Locations
- BMJ Quality & Safety (publishedVersion)
- PubMed (publishedVersion)
- Durham Research Online (Durham University) (submittedVersion, cc-by)
- Funders
- Stanford University School of Medicine (Medical Scholars Research Program Grant (30521), Medical Scholars Research Program Grant (30879))
- National Palliative Care Research Center (Junior Investigator Career Development Award)
- Cambia Health Foundation (Sojourns Scholar Leadership Program)
- Global Brain Health Institute (Atlantic Fellowship for Equity in Brain Health)
- California Department of Public Health (Alzheimer’s Disease Research Award)
- Clinical and Translational Science Institute, University of California, San Francisco (KL2 (1KL2TR001870-02))
- National Human Genome Research Institute (Stanford Training Program in Ethical, Legal, and Social Implications Research (HG00895301))
- National Institute on Aging (ADRD supplement (3R01NR018161-02S1), Grants for Early Medical/Surgical Subspecialty Tra)
- Alzheimer’s Society UK
- 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 › Ethics and bioethics in healthcare
- Health Sciences › Medicine › Emergency Medicine › Cardiac Arrest and Resuscitation
- Keywords
- do-not-resuscitate orders, end-of-life care, resuscitation decisions, life-sustaining treatment, physician communication, hospital variation, treatment intensity
- MeSH terms
- Hospitals, Humans, Physicians, Terminal Care, Resuscitation Orders, Qualitative Research
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