title: Code status discussions between attending hospitalist physicians and medical patients at hospital admission.
abstract: BACKGROUND
  Bioethicists and professional associations give specific recommendations for discussing cardiopulmonary resuscitation (CPR).
  
  
  OBJECTIVE
  To determine whether attending hospitalist physicians' discussions meet these recommendations.
  
  
  METHODS
  Cross-sectional observational study on the medical services at two hospitals within a university system between August 2008 and March 2009.
  
  
  METHODS
  Attending hospitalist physicians and patients who were able to communicate verbally about their medical care.
  
  
  METHODS
  We identified code status discussions in audio-recorded admission encounters via physician survey and review of encounter transcripts. A quantitative content analysis was performed to determine whether discussions included elements recommended by bioethicists and professional associations. Two coders independently coded all discussions; Cohen's kappa was 0.64-1 for all reported elements.
  
  
  RESULTS
  Audio-recordings of 80 patients' admission encounters with 27 physicians were obtained. Eleven physicians discussed code status in 19 encounters. Discussions were more frequent in seriously ill patients (OR 4, 95% CI 1.2-14.6), yet 66% of seriously ill patients had no discussion. The median length of the code status discussions was 1 min (range 0.2-8.2). Prognosis was discussed with code status in only one of the encounters. Discussions of patients' preferences focused on the use of life-sustaining interventions as opposed to larger life goals. Descriptions of CPR as an intervention used medical jargon, and the indication for CPR was framed in general, as opposed to patient-specific scenarios. No physician quantitatively estimated the outcome of or provided a recommendation about the use of CPR.
  
  
  CONCLUSIONS
  Code status was not discussed with many seriously ill patients. Discussions were brief, and did not include elements that bioethicists and professional associations recommend to promote patient autonomy. Local and national guidelines, research, and clinical practice changes are needed to clarify and systematize with whom and how CPR is discussed at hospital admission.
authors.affiliation: Division of Hospital Medicine, University of California, San Francisco, 521 Parnassus Avenue, Box 0903, San Francisco, CA 94143-0903, USA. anderson.wg@gmail.com
authors.forename: Wendy G
authors.initials: WG
authors.lastname: Anderson
authors.forename: Rebecca
authors.initials: R
authors.lastname: Chase
authors.forename: Steven Z
authors.initials: SZ
authors.lastname: Pantilat
authors.forename: James A
authors.initials: JA
authors.lastname: Tulsky
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Auerbach
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation / Q000379:methods / Q000523:psychology; D003142:Communication; D003430:Cross-Sectional Studies; D005260:Female; D020445:Hospitalists / Q000379:methods; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital / Q000523:psychology; D008875:Middle Aged; D010343:Patient Admission; D010361:Patients / Q000523:psychology; D010817:Physician-Patient Relations; D016414:Resuscitation Orders / Q000523:psychology