title: Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study.
abstract: In Asian societies including Pakistan, a complex background of illiteracy, different familial dynamics, lack of patient's autonomy, religious beliefs, and financial constraints give new dimensions to code status discussion. Barriers faced by physicians during code status discussion in these societies are largely unknown.
  
  
  
  To determine the barriers and perceptions in discussion of code status by physicians.
  
  
  
  Questionnaire-based cross-sectional study.
  
  
  
  This study was conducted in the Department of Medicine of The Aga Khan University Hospital, Karachi, Pakistan. A total of 134 physicians who had discussed at least five code statuses in their lifetime were included.
  
  
  
  A total of 77 (57.4%) physicians responded. Family-related barriers were found to be the most common barriers. They include family denial (74.0%), level of education of family (66.2%), and conflict between individual family members (66.2%). Regarding personal barriers, lack of knowledge regarding prognosis (44.1%), personal discomfort in discussing death (29.8%), and fear of legal consequences (28.5%) were the top most barriers. In hospital-related barriers, time constraint (57.1%), lack of hospital administration support (48.0%), and suboptimal nursing care after do not resuscitate (48.0%) were the most frequent. There were significant differences among opinions of trainees when compared to those of attending physicians.
  
  
  
  Family-related barriers are the most frequent roadblocks in the end-of-life care discussions for physicians in Pakistan. Strengthening communication skills of physicians and family education are the potential strategies to improve end-of-life care. Large multi-center studies are needed to better understand the barriers of code status discussion in developing countries.
authors.affiliation: 1 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Ahsan A
authors.initials: AA
authors.lastname: Syed
authors.affiliation: 1 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Aysha
authors.initials: A
authors.lastname: Almas
authors.affiliation: 1 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Quratulain
authors.initials: Q
authors.lastname: Naeem
authors.affiliation: 2 Thomas J. Long School of Pharmacy & Health Sciences, University of the Pacific, Stockton, CA, USA.
authors.forename: Umer F
authors.initials: UF
authors.lastname: Malik
authors.affiliation: 1 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Tariq
authors.initials: T
authors.lastname: Muhammad
mesh_terms: D000328:Adult; D001293:Attitude to Death; D003144:Communication Barriers; D016638:Critical Illness / Q000628:therapy*; D003430:Cross-Sectional Studies; D003906:Developing Countries; D005190:Family; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010154:Pakistan; D010353:Patient Education as Topic; D010817:Physician-Patient Relations; D016414:Resuscitation Orders; D013727:Terminal Care; D062606:Tertiary Care Centers
keywords: Do-not-resuscitate orders; Pakistan; perceptions; physicians