Training improved resident-led code status discussions in some ways but not others, according to a recent study.1 “Our findings — that despite communication skills training, resident physicians still struggle with the more complex tasks involved in discussing resuscitation preferences — weren’t necessarily surprising,” says Rashmi K. Sharma, MD, MHS, assistant professor of medicine in the Section of Palliative Medicine at Northwestern University’s Feinberg School of Medicine in Chicago.

The study highlights the need for more advanced training techniques, says Sharma. Fifty-six residents on the internal medicine service in July 2010 participated in the study, with 25 completing code status discussion skills training and 31 in a control group. Six months later, all 56 residents completed a simulated code status discussion.1

Trained residents did a better job exploring patient values and goals, using a shared decision-making approach, and making a recommendation, than residents who did not receive the training.1 “So there is hope that training can make a difference,” says Sharma.

However, many residents failed to discuss resuscitation outcomes and quality of life. “Many of the residents in our study had a particularly challenging time transitioning from a broader conversation about goals of care to talking about code status specifically,” notes Sharma.

Trained residents were less likely to frame the decision as one solely to be made by the patient, but many struggled with this aspect of the conversation. “Residents are still frequently placing the onus of decision-making solely on the patient, in an attempt to support patient autonomy,” says Sharma.

Residents aren’t giving patients adequate information to make such a complex decision — an obstacle in shifting current practice to more of a shared decision-making approach. “Clinicians and patients should arrive at a decision together, based on the patient’s values and goals and medical knowledge about likely outcomes,” says Sharma.

In order to effectively conduct conversations on end-of-life preferences, says Sharma, trainees likely need to practice skills over time with feedback from skilled clinicians. “Ultimately, the goal is to help patients receive end-of-life care that is aligned with their values and goals,” says Sharma. “Resuscitation preferences is just one part of this bigger discussion about goals of care.”

Code status discussions “need to be part of a broader conversation with patients and families. All clinicians need to make this a priority, not just those who are most passionate about the topic,” says Anita J. Tarzian, PhD, RN, program coordinator of the Maryland Healthcare Ethics Committee Network in Baltimore.

Regardless of who has the discussion, the content of the conversation is a central concern; clinicians often focus solely on the patient’s resuscitation status. “We see routinely that people are focusing too narrowly,” says Tarzian. “If you are really interested in giving patient-centered care and having end-of-life care preferences known, just focusing on resuscitation orders is not the way to go.”

A request for an ethics consult sometimes reveals the need for education on a broader issue, in addition to answering the specific question asked. “Oftentimes, there are other ethical issues than just that narrow question prompting the call for help,” notes Tarzian.

Often, clinicians request an ethics consult to inquire if they have to offer an invasive life support treatment that they don’t think will benefit a patient who is dying. “But it’s a broader question than whether they have to offer the intervention,” says Tarzian. In these cases, resuscitation status is relevant because the medical team believes the patient is dying. However, there is a bigger picture to consider. “Must physicians offer interventions they don’t think will benefit the patient? No,” says Tarzian. “It’s up to the physicians to decide what should be on and off the table as regards the medical standard of care.”

For example, if a patient is not a candidate for a heart transplant or a left ventricular assist device, offering these options would only serve to confuse the patient or surrogate. “Moreover, if a patient is clearly dying, there are likely other interventions that may benefit the patient that should be explored, even if the treating clinicians didn’t mention this in their request for ethics consultation,” says Tarzian.

Sometimes the ethics consultant’s role is to help the clinical team narrow down the options by forging consensus surrounding which treatments they think, using a reasonable degree of medical certainty, should be presented to the patient. “Other times the ethics consultant’s role is to broaden the options — to help clinicians, patients, or family members to consider options or perspectives that weren’t previously considered,” says Tarzian. A dying patient may be discharged without hospice or palliative care follow-up because the patient isn’t receptive to discussing hospice or palliative care. “In this situation, the ethics consultant could model how to approach this topic in a way that focuses more on what will be done to support him rather than what won’t be done,” suggests Tarzian. “The way this plays out is important.”

If the ethics consultant does all the communication groundwork without any other clinician or trainee being present, an opportunity for skill building is lost. “Also, if they just come in and tell clinicians what to do, some of the value of what they bring to the table is lost,” adds Tarzian.

Ideally, the ethics consultant is successful if he or she can help involved parties feel good about decisions made for patients who are dying. “If there are recurrent barriers to achieving this, something needs to be done at the systems level,” says Tarzian.

Reference

  1. RK, Jain N, Peswani N, et al. Unpacking resident-led code status discussions: results from a mixed methods study. J Gen Intern Med 2014; 29(5):750-7

SOURCES

  • Rashmi K. Sharma, MD, MHS, Assistant Professor of Medicine, Section of Palliative Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Phone: (312) 926-0096. Fax: (312) 926-4588. Email: rasharma@nmh.org.
  • Anita J. Tarzian, PhD, RN, Program Coordinator, Maryland Healthcare Ethics Committee Network, Baltimore. Phone: (410) 706-1126. Fax: (410) 706-0407. Email: atarzian@law.umaryland.edu.