What I Did Before
Most internal medicine practitioners, leaners and attendings alike, include “code status” as an issue on an in-patient’s problem list. Often “not addressed overnight” or “needs to be discussed” is left as the plan. Generally, clinicians appreciate the importance of this task. Most, however, confuse this medical treatment decision – what is the patient willing to consent to as treatment if his/her condition were to seriously deteriorate? – as advance care planning or goals of care. Even more problematic is the need to answer these treatment consent questions in an Emergency Room when the patient is acutely ill.
Yet, even once the patient is more stabilized on a Medical Ward, conversations about goals of care are often still reduced to binary yes or no questions about cardiopulmonary resuscitation and/or Intensive Care Unit admission. All too often, once the CPR status is determined, a more robust, patient-centered goals of care conversation ceases to continue. Most physicians and trainees feel inadequately prepared to conduct difficult and comprehensive goals of care or end-of-life discussions (1, 2). Despite the disconcerting data indicating that many cancer patients have their first end-of-life care conversation during an acute hospitalization (3) or that many dialysis patients never have these discussions at all (4), a change in practice has been slow and difficult.
This cascade of unfortunate events and missed opportunities results in a worrisome mismatch in treatment and care plans between what is documented by clinicians and what the seriously ill patient has already thought about (5). We need to become less accepting of discharge summaries that read: “Code Status: the patient was full code in hospital. This should continue be explored as an outpatient.” These conversations have been incentivized for the physician through Advanced Care Planning billing codes, as outlined by This Changed My Practice contributor Dr. Catherine Clelland (6, http://thischangedmypractice.com/acp-for-patients-with-multiple-co-morbidities/). Furthermore, with data demonstrating the benefits of early goals of care conversations (7), these conversations must shift to being commonplace for patients across the continuum of care.