The Differences in Code Status Conversation Approaches Reported by Emergency Medicine and Palliative Care Clinicians: A Mixed-Method Study

Authors

Kei Ouchi
Thidathit Prachanukool
Emily L Aaronson
Joshua R Lakin
Masaya Higuchi
Shan W Liu
Maura Kennedy
Anna C Revette
Anita N Chary
Jenson Kaithamattam
Brandon Lee
Thanh H Neville
Mohammad A Hasdianda
Rebecca Sudore
Mara A Schonberg
James A Tulsky
Susan D Block

Publication Date

1-31-2024

Journal

Academic Emergency Medicine

DOI

10.1111/acem.14818

PMID

37814372

PMCID

PMC10794002

PubMedCentral® Posted Date

1-17-2024

PubMedCentral® Full Text Version

Author MSS

Published Open-Access

yes

Keywords

Humans, Palliative Care, Quality of Life, Communication, Surveys and Questionnaires, Emergency Medicine

Abstract

BACKGROUND: During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different.

METHODS: We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews.

RESULTS: Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies.

CONCLUSIONS: Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.

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