Executive Summary

Psychiatric inpatients were less likely to have an order on admission regarding code status compared to medical inpatients, according to a recent study.

• Providers may hesitate to have discussions with psychiatric inpatients due to concerns about capacity.

• Bioethicists can help with challenging cases common in the psychiatric hospital setting.

• Providers need to document not just code status, but other treatment wishes as well.


Psychiatric inpatients were less likely to have an order on admission regarding code status compared to medical inpatients, according to a recent study.1 Researchers conducted a retrospective chart review of patients who were hospitalized during a 12-month period in 2008; 276 psychiatric charts and 317 general medical patient charts were reviewed. Key findings include the following:

• Ninety-six percent of medical patients had a code status order documented on admission, compared to 65% of psychiatric patients.

• Psychiatric inpatients had more Do Not Resuscitate/Do Not Intubate orders, more frequent change in code status order and a higher percentage of advance directives.

• Psychiatric inpatients were less likely to have had a discussion regarding the need for acute resuscitative interventions with their provider.1

“The study’s findings were consistent with what we had hypothesized,” says Alastair McKean, MD, one of the study’s authors. McKean is an instructor in the Mayo Clinic’s Department of Psychiatry and Psychology in Rochester, MN.

The Patient Self-Determination Act mandates that a code status needs to be in place for every hospitalized patient. “The concern when code status discussions are not had is that a patient’s autonomy to choose the level of end-of-life care that she or he desires is not being respected,” says McKean.

Providers may be hesitant to have these discussions with psychiatric inpatients because of concerns regarding capacity. “The acute nature of the psychiatric pathology or cognitive impairments might limit patient capacity to share a preference,” says McKean. Additionally, some providers might not feel that discussion of code status is pertinent if the patient is medically stable with every expectation of surviving until discharge.

“This is an area of ongoing research,” notes McKean. A recent study surveyed 30 psychiatric faculty and trainees; respondents felt it was important to discuss code status with each admission.2 McKean, the study’s lead author, says bioethicists can help with challenging cases — when a suicidal patient does not want to be resuscitated, when a terminally ill patient attempts suicide, or when a patient at the end of life requests hastened death.

“Once there is a better understanding of the barriers that prevent these discussions with psychiatric inpatients, tailoring educational interventions for psychiatric providers will be important,” says McKean.

Too often, documentation about patients’ end-of-life wishes are reduced to “checking the box,” says Charles Hite, MA, CIP, director of biomedical and research ethics at Carilion Clinic in Roanoke, VA. The patient’s code status is documented but without any meaningful conversation or information being given.

“What I see happening is more and more hospitals are trying to adopt something like the POLST [Physician Orders for Life-Sustaining Treatment] Paradigm,” says Hite. Using this approach, targeted conversations are directed at the patient population that can benefit most from it. “I don’t see the need to have a code status conversation with a 35-year-old coming in to have an elbow fixed. But it is necessary for an 84-year-old coming in for a third exacerbation of congestive heart failure,” says Hite. Such a conversation would, ideally, cover not only the patient’s code status, but also other treatment wishes. “Then we need to have a routinized ways of having those conversations, so they are not seen as a big deal,” Hite says.

The Patient Self-Determination Act of 1990 aimed to ensure that patients had advance directives and that these were part of the patient’s chart. “But the way it got implemented was that it just became a question to ask at admission; it was often done at a very low level as far as who was asking the question,” says Hite. Residents are sometimes taught to quickly ask the question about whether the patient wants to be coded or not and move onto the next task. “It is not a meaningful conversation, and it is probably being directed at too many people,” Hite says. “It needs to target those who have chronic, life-limiting illnesses, and those who are likely who be rehospitalized.”

In the hospital setting, conversations are occurring too late and in a setting that’s not conducive to thoughtful discussions on end-of-life care. “Frankly, when you’re getting admitted to the hospital is probably not a good time,” says Hite. “We need to push it further upstream and have those conversations in the primary care setting, if possible.”

That allows for enough time for the patient to consider what level of care he or she would like — whether aggressive care, more limited care, or just comfort care — instead of just whether the patient wants cardiopulmonary resuscitation if his or her heart stops. “Code status discussions need to be part of a larger conversation,” says Hite. “All of those decisions take time to talk about.”

The Carilion Clinic is piloting a program to promote advance care planning in the primary care setting. Nurses are trained in advance care planning, including how to start the conversation with patients, and patients are shown an informative video. Physicians, who receive two hours of training with role-playing exercises, enter the discussion once the patient has had time to consider his or her options.

“Nurses look at the schedule for the next day and flag patients for whom it’s appropriate to have this conversation,” Hite explains. Physicians either follow up with the patient at the end of the visit or bring it up at the next visit.

“There are some logistical challenges to having these conversations in the hospital,” notes Hite. “The difficulty is that patients are in the hospital for such a short length of stay, and oftentimes have other things on their minds.”

If discussions routinely occur for all patients meeting certain criteria, this serves to clarify that the motivation is not to deny treatment or save money. “It’s certainly to the patient’s benefit to be aware of the options they have,” says Hite. “It’s all about patient choice. If they want aggressive treatment, they can make that known.”


  1. Warren MB, Lapid MI, McKean AJ, et al. Code status discussions in psychiatric and medical inpatients. J Clin Psychiatry 2015; 76(1):49-53.
  2. McKean AJS, Lapid MI, Geske JR, et al. The importance of code status discussions in the psychiatric hospital: Results of a single site survey of psychiatrists. Academic Psychiatry 2015; 39(2):200-203.


  • Charles Hite, MA, CIP, Director of Biomedical & Research Ethics, Carilion Clinic, Roanoke, VA. Phone: (540) 981-8096. Fax: (540) 985-5323. Email: cahite@carilionclinic.org.
  • Alastair McKean, MD, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN. Email: Mckean.Alastair@mayo.edu.