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Background Many problems exist regarding inpatient code status: advance directives are rarely completed in outpatient and inpatient settings; patients preferences regarding code status are often not elicited; physicians do not provide adequate information to allow patients to make informed decisions about code status; code status discussions are often delayed during an admission until it is too late for the patients to participate; and providers inappropriately extrapolate DNR orders to limit other treatments (such as artificial nutrition, ICU admission, etc.) Most hospitals default to 'Full Code' as the status for patients admitted, particularly in patients with whom a code status discussion cannot or has not taken place. In many cases, confirmation of 'Full Code' does not occur later when these discussions become possible. These problems can result in patients receiving care they would not wish or choose. Purpose At the University of New Mexico (UNM), an academic safety net hospital, a multidisciplinary Advance Directives Task Force formed to address these issues. An initial survey found that <2% of inpatients had advance directives. The goals of the task force were to improve the above issues around code status and increase advance directive completion, in an effort to improve patient care at end of life. Description A multi-disciplinary team at the University of New Mexico met regularly for 2 years to address these concerns. Quality improvement measures included: 1) A revision of the hospital Code Status Policy including the following: a) All adult admissions will have a code status discussion, identification of a surrogate decision maker, and a code status note written b) Code status orders are written for all adult inpatients and include the options of Presumed Full Code (for patients with whom a discussion cannot take place on admission), Confirmed Full Code (after discussion takes place with patient or surrogate), or DNR (eliminating 'partial code' status orders) 2) Process Improvements included: a) Modification of existing orders and order sets in EMR b) Development of standardized templates for code status discussion and surrogate decision maker identification notes c) Revision of patient handouts about Advance Directives in literacy appropriate language d) Education for physicians about 'how to have a code status discussion' e) Hospital-wide education to all staff about these changes Conclusions As a specialty, hospital medicine needs to take a more proactive role in ensuring that patients make informed decisions and receive all and only the care they desire. To make this cultural change in our nationwide practice, we submit these standards we hope to be adopted by other institutions including the use of 'presumed' and 'confirmed' code statuses, the expectation to have code status discussions on all admissions with identification of surrogate decision maker, and to support increased education to hospitalist in engaging in these discussions.'


Presented at Society of Hospital Medicine, 05/18/2013, National Harbor, MD