title: Code status orders and goals of care in the medical ICU.
abstract: BACKGROUND
  Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care.
  
  
  METHODS
  We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders.
  
  
  RESULTS
  Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents' average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status (P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care.
  
  
  CONCLUSIONS
  Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients' code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Gehlbach
authors.affiliation: Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, IA.
authors.forename: Laura A
authors.initials: LA
authors.lastname: Shinkunas
authors.affiliation: Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.
authors.forename: Valerie L
authors.initials: VL
authors.lastname: Forman-Hoffman
authors.affiliation: Division of Pulmonary and Critical Care Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.
authors.forename: Karl W
authors.initials: KW
authors.lastname: Thomas
authors.affiliation: Division of Pulmonary and Critical Care Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Schmidt
authors.affiliation: Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, IA; Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA. Electronic address: lauris-kaldjian@uiowa.edu.
authors.forename: Lauris C
authors.initials: LC
authors.lastname: Kaldjian
mesh_terms: D016887:Cardiopulmonary Resuscitation / Q000592:standards*; D005260:Female; D006040:Goals; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D008297:Male; D008875:Middle Aged; D010347:Patient Care Planning / Q000458:organization & administration*; D016414:Resuscitation Orders; D012189:Retrospective Studies