David Gonzales, MD

Despite an ideal of dying at home, most Americans die in hospitals.1 Patients and families are clear about what they need from the healthcare system at the end of life: relief of distressing symptoms, the opportunity to communicate with physicians and others about death and dying, and the assurance that they will be attended to and comforted by their physicians as they approach death.2, 3 However, discussions about patient preferences for care occur infrequently,47 even though patients want to discuss care with their doctor,68 and physicians believe these discussions are their responsibility.9

The most prominent work in this area occurred in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) study, which focused on patients with advanced disease, often in the intensive care unit.4 Furthermore, few studies have focused on general medical patients, and healthcare has changed in important ways since SUPPORT's publication. First, the Patient Self‐Determination Act (PSDA) requires that all patients be asked about their care wishes at the time of admission and document the presence of an advanced directive.10, 11 Second, there is growing awareness of the need to improve palliative care for all hospitalized patients, with many advocating that hospitalization itself is a reason to ask about patient's preferences for care regardless of a patient's level of chronic or acute illness.12 Finally, emergence of hospitalists,1316 movement toward closed intensive care units,17, 18 and changes in residency training have increased segmentation in care of hospitalized patients.15, 18

To overcome limitations of previous literature and update our knowledge of how care discussions take place in the current healthcare environment, we analyzed data from a large study of patients admitted to general medicine services at 6 academic centers. Using this robust dataset, which included prospectively collected information about preferences for communication with their physician, we performed statistical analyses to understand which patient clinical, sociodemographic, and preference‐related factors, as well as factors related to their site of care, were associated with documentation that a code status discussion took place at the time of hospital admission.

PATIENTS AND METHODS

RESULTS

DISCUSSION

In this multicenter study of hospitalized general medical patients, documentation of CDs were highly dependent on where patients received care and whether patients had previous documentation of a care plan. In contrast, although clinical, prognostic, and socioeconomic factors were also associated with whether physicians documented asking patients about their wishes for care, the influence of these factors was modest.

Improving communication between patients and their physicians during an episode of acute illness has been a long‐standing goal, with the Study to Understand Prognoses and Preferences for Outcomes of Treatment (SUPPORT) trial providing the most notable example of an effort to improve patient care through aligning patient wishes, prognosis, and aggressiveness for care. However, even the SUPPORT interventiona robust, well‐implemented, and highly labor‐intensive strategywas not able to achieve this goal. In their summary of SUPPORT study findings, the authors suggested that the likelihood of and effectiveness of communication in seriously ill patients may be powerfully influenced by patient and caregiver culture4; our findings may partially confirm SUPPORT's conclusions.

Preexisting documentation in our study would not have included mandated documentation that someone had given the patient information about advance directives (as mandated by the PSDA), but rather a specification for that advance care plan. This distinction means that preexisting documentation in our study represented a previous decision by the patient (or the patient and their physician) to have made a plan, and an association with hospital discussions may be because the first conversation is the hardest to undertake; subsequent discussions then represent confirmatory or clarifying discussions that may be less difficult to broach (particularly for less experienced trainees). A CD may have also been prompted when documentation was unclear, or when a change in prognosis took place (eg, a new diagnosis of metastatic cancer).22 Alternatively, a preexisting plan may serve as a reminder for clinicians to discuss code status, signify patients who are more willing to broach this subject, and either seem more approachable or bring up the topic themselves.

The influence of site on documentation and CD provides additional evidence that caregiver culture played a role in CDs. Although this variation may have been in part due to culture around documentation practices more generally, it is important to note that none of our participating centers had a policy for documentation of care wishes or patient‐doctor communication, or a policy mandating these discussions in any specific patient group. Furthermore, site‐related differences were seen even in patients with no preexisting documentation, and were seen after adjustment for other documentation or communication practices (eg, documenting a discussion with the patient's primary care provider), making it unlikely that documentation practices are solely responsible for our results. Persistence of variations in care documentation raises interesting questions, particularly when one considers recent data describing variations in end‐of‐life care between similar academic centers (one of which was a participating site in this trial).23 Given that the sites in our study represent diverse institutions yet share a number of characteristics, understanding the specific practices or aspects of medical culture that promote conversations may provide insights in how to improve this promotion elsewhere.

Our results would argue that mandates to document code status on admission may be unlikely to improve communication unless sites also develop an approach to using this newly documented information as a prompt for subsequent discussions. In nursing home settings, documentation of advance directives may reduce resource use, but it is unclear whether similar effects will be seen in hospital settings.24 It is also a challenge to insure that documentation of a care plan in the nursing home is communicated to the providers in the hospital.25 The PSDA was a first step in this direction, but its effects on improving communication are uncertain.26 Our results would confirm that the PSDA or systems to mandate documentation are not solutions in themselves, but are 2 steps in a larger process.

We do not want to discount our findings of less frequent CDs among patients of lower socioeconomic status, where gaps in quality of care, communication, and outcomes are well‐recognized.27 As such, our results delineate yet another area where practice can and should be improved for vulnerable patients. However, factors related to site of care and documentation may provide opportunities to improve care even more profoundly and within a fairly discrete (if complex) acute episode of care. Having said this, our results also demonstrate a potential pitfall of using code status documentation for risk‐adjustment, because such notation may be more dependent on local documentation patterns than clinical appropriateness.

Our study has a number of limitations. As an observational study, our findings are likely prone to biases related to unadjusted confounding due to comorbidity. The influence of comorbidity would seem to have been most important in biasing the effects of preexisting documentation, where documentation would be associated with more unaccounted comorbidity. However, there were no differences in documentation even after accounting for prognosis by adjusting for age, functional status, and a valid comorbidity score.28 As we have pointed out, our key outcome is based on documentation of communication and not actual communication, and as such may be biased in subtle ways not related to site of care or the items tested in our model. While we cannot directly eliminate the possibility of documentation biases in our results using statistical methods, it is important to point out that our chart abstraction protocol used highly specific criteria to detect these discussions, and therefore may under‐detect discussions which may have been documented in less detail. Our study did not examine whether documentation of CDs influenced subsequent care. However, previous studies have shown that advance care planning has only a minor influence on care.29 However, communication about preferences at the time of admission, when the need for specific care decisions may be more evident, may be more likely to influence hospital care. Our results show that previous documentation is associated with discussions early in an admission. Such discussion may affect care, even if the decision made is different than what was previously documented. In addition, patients who were included in our study (those able to provide consent and participate in an interview) may be healthier or more cognitively intact than a general population of hospitalized patients. However, how this would have affected our results is unclear. Being able to speak and consent for oneself are key facilitators to communication, but sicker patients who cannot consent or speak for themselves might also be more likely to have care planning decisions made based on illness severity; documentation in these patients may be more driven by whether such notes were required because of the involvement of home health services (or skilled nursing facilities). Finally, although our study is one of the largest examinations of in‐hospital communication to date and its implications for resident education are worth noting, the sites involved in the MCHS may not be representative of nonteaching hospitals, or community‐based teaching hospitals.

Our results suggest that, although comorbid illness and socioeconomic status play an important role in determining which patients receive CDs at the time of admission, these factors are substantially less powerful than preexisting documentation practices and culture or care practices specific to their site of care. These results suggest that future work should consider organizational characteristics and culture as important targets for interventions to improve care planning in hospitalized patients.

Despite an ideal of dying at home, most Americans die in hospitals.1 Patients and families are clear about what they need from the healthcare system at the end of life: relief of distressing symptoms, the opportunity to communicate with physicians and others about death and dying, and the assurance that they will be attended to and comforted by their physicians as they approach death.2, 3 However, discussions about patient preferences for care occur infrequently,47 even though patients want to discuss care with their doctor,68 and physicians believe these discussions are their responsibility.9

The most prominent work in this area occurred in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) study, which focused on patients with advanced disease, often in the intensive care unit.4 Furthermore, few studies have focused on general medical patients, and healthcare has changed in important ways since SUPPORT's publication. First, the Patient Self‐Determination Act (PSDA) requires that all patients be asked about their care wishes at the time of admission and document the presence of an advanced directive.10, 11 Second, there is growing awareness of the need to improve palliative care for all hospitalized patients, with many advocating that hospitalization itself is a reason to ask about patient's preferences for care regardless of a patient's level of chronic or acute illness.12 Finally, emergence of hospitalists,1316 movement toward closed intensive care units,17, 18 and changes in residency training have increased segmentation in care of hospitalized patients.15, 18

To overcome limitations of previous literature and update our knowledge of how care discussions take place in the current healthcare environment, we analyzed data from a large study of patients admitted to general medicine services at 6 academic centers. Using this robust dataset, which included prospectively collected information about preferences for communication with their physician, we performed statistical analyses to understand which patient clinical, sociodemographic, and preference‐related factors, as well as factors related to their site of care, were associated with documentation that a code status discussion took place at the time of hospital admission.

PATIENTS AND METHODS

RESULTS

DISCUSSION

In this multicenter study of hospitalized general medical patients, documentation of CDs were highly dependent on where patients received care and whether patients had previous documentation of a care plan. In contrast, although clinical, prognostic, and socioeconomic factors were also associated with whether physicians documented asking patients about their wishes for care, the influence of these factors was modest.

Improving communication between patients and their physicians during an episode of acute illness has been a long‐standing goal, with the Study to Understand Prognoses and Preferences for Outcomes of Treatment (SUPPORT) trial providing the most notable example of an effort to improve patient care through aligning patient wishes, prognosis, and aggressiveness for care. However, even the SUPPORT interventiona robust, well‐implemented, and highly labor‐intensive strategywas not able to achieve this goal. In their summary of SUPPORT study findings, the authors suggested that the likelihood of and effectiveness of communication in seriously ill patients may be powerfully influenced by patient and caregiver culture4; our findings may partially confirm SUPPORT's conclusions.

Preexisting documentation in our study would not have included mandated documentation that someone had given the patient information about advance directives (as mandated by the PSDA), but rather a specification for that advance care plan. This distinction means that preexisting documentation in our study represented a previous decision by the patient (or the patient and their physician) to have made a plan, and an association with hospital discussions may be because the first conversation is the hardest to undertake; subsequent discussions then represent confirmatory or clarifying discussions that may be less difficult to broach (particularly for less experienced trainees). A CD may have also been prompted when documentation was unclear, or when a change in prognosis took place (eg, a new diagnosis of metastatic cancer).22 Alternatively, a preexisting plan may serve as a reminder for clinicians to discuss code status, signify patients who are more willing to broach this subject, and either seem more approachable or bring up the topic themselves.

The influence of site on documentation and CD provides additional evidence that caregiver culture played a role in CDs. Although this variation may have been in part due to culture around documentation practices more generally, it is important to note that none of our participating centers had a policy for documentation of care wishes or patient‐doctor communication, or a policy mandating these discussions in any specific patient group. Furthermore, site‐related differences were seen even in patients with no preexisting documentation, and were seen after adjustment for other documentation or communication practices (eg, documenting a discussion with the patient's primary care provider), making it unlikely that documentation practices are solely responsible for our results. Persistence of variations in care documentation raises interesting questions, particularly when one considers recent data describing variations in end‐of‐life care between similar academic centers (one of which was a participating site in this trial).23 Given that the sites in our study represent diverse institutions yet share a number of characteristics, understanding the specific practices or aspects of medical culture that promote conversations may provide insights in how to improve this promotion elsewhere.

Our results would argue that mandates to document code status on admission may be unlikely to improve communication unless sites also develop an approach to using this newly documented information as a prompt for subsequent discussions. In nursing home settings, documentation of advance directives may reduce resource use, but it is unclear whether similar effects will be seen in hospital settings.24 It is also a challenge to insure that documentation of a care plan in the nursing home is communicated to the providers in the hospital.25 The PSDA was a first step in this direction, but its effects on improving communication are uncertain.26 Our results would confirm that the PSDA or systems to mandate documentation are not solutions in themselves, but are 2 steps in a larger process.

We do not want to discount our findings of less frequent CDs among patients of lower socioeconomic status, where gaps in quality of care, communication, and outcomes are well‐recognized.27 As such, our results delineate yet another area where practice can and should be improved for vulnerable patients. However, factors related to site of care and documentation may provide opportunities to improve care even more profoundly and within a fairly discrete (if complex) acute episode of care. Having said this, our results also demonstrate a potential pitfall of using code status documentation for risk‐adjustment, because such notation may be more dependent on local documentation patterns than clinical appropriateness.

Our study has a number of limitations. As an observational study, our findings are likely prone to biases related to unadjusted confounding due to comorbidity. The influence of comorbidity would seem to have been most important in biasing the effects of preexisting documentation, where documentation would be associated with more unaccounted comorbidity. However, there were no differences in documentation even after accounting for prognosis by adjusting for age, functional status, and a valid comorbidity score.28 As we have pointed out, our key outcome is based on documentation of communication and not actual communication, and as such may be biased in subtle ways not related to site of care or the items tested in our model. While we cannot directly eliminate the possibility of documentation biases in our results using statistical methods, it is important to point out that our chart abstraction protocol used highly specific criteria to detect these discussions, and therefore may under‐detect discussions which may have been documented in less detail. Our study did not examine whether documentation of CDs influenced subsequent care. However, previous studies have shown that advance care planning has only a minor influence on care.29 However, communication about preferences at the time of admission, when the need for specific care decisions may be more evident, may be more likely to influence hospital care. Our results show that previous documentation is associated with discussions early in an admission. Such discussion may affect care, even if the decision made is different than what was previously documented. In addition, patients who were included in our study (those able to provide consent and participate in an interview) may be healthier or more cognitively intact than a general population of hospitalized patients. However, how this would have affected our results is unclear. Being able to speak and consent for oneself are key facilitators to communication, but sicker patients who cannot consent or speak for themselves might also be more likely to have care planning decisions made based on illness severity; documentation in these patients may be more driven by whether such notes were required because of the involvement of home health services (or skilled nursing facilities). Finally, although our study is one of the largest examinations of in‐hospital communication to date and its implications for resident education are worth noting, the sites involved in the MCHS may not be representative of nonteaching hospitals, or community‐based teaching hospitals.

Our results suggest that, although comorbid illness and socioeconomic status play an important role in determining which patients receive CDs at the time of admission, these factors are substantially less powerful than preexisting documentation practices and culture or care practices specific to their site of care. These results suggest that future work should consider organizational characteristics and culture as important targets for interventions to improve care planning in hospitalized patients.

Despite an ideal of dying at home, most Americans die in hospitals.1 Patients and families are clear about what they need from the healthcare system at the end of life: relief of distressing symptoms, the opportunity to communicate with physicians and others about death and dying, and the assurance that they will be attended to and comforted by their physicians as they approach death.2, 3 However, discussions about patient preferences for care occur infrequently,47 even though patients want to discuss care with their doctor,68 and physicians believe these discussions are their responsibility.9

The most prominent work in this area occurred in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) study, which focused on patients with advanced disease, often in the intensive care unit.4 Furthermore, few studies have focused on general medical patients, and healthcare has changed in important ways since SUPPORT's publication. First, the Patient Self‐Determination Act (PSDA) requires that all patients be asked about their care wishes at the time of admission and document the presence of an advanced directive.10, 11 Second, there is growing awareness of the need to improve palliative care for all hospitalized patients, with many advocating that hospitalization itself is a reason to ask about patient's preferences for care regardless of a patient's level of chronic or acute illness.12 Finally, emergence of hospitalists,1316 movement toward closed intensive care units,17, 18 and changes in residency training have increased segmentation in care of hospitalized patients.15, 18

To overcome limitations of previous literature and update our knowledge of how care discussions take place in the current healthcare environment, we analyzed data from a large study of patients admitted to general medicine services at 6 academic centers. Using this robust dataset, which included prospectively collected information about preferences for communication with their physician, we performed statistical analyses to understand which patient clinical, sociodemographic, and preference‐related factors, as well as factors related to their site of care, were associated with documentation that a code status discussion took place at the time of hospital admission.

PATIENTS AND METHODS

RESULTS

DISCUSSION

In this multicenter study of hospitalized general medical patients, documentation of CDs were highly dependent on where patients received care and whether patients had previous documentation of a care plan. In contrast, although clinical, prognostic, and socioeconomic factors were also associated with whether physicians documented asking patients about their wishes for care, the influence of these factors was modest.

Improving communication between patients and their physicians during an episode of acute illness has been a long‐standing goal, with the Study to Understand Prognoses and Preferences for Outcomes of Treatment (SUPPORT) trial providing the most notable example of an effort to improve patient care through aligning patient wishes, prognosis, and aggressiveness for care. However, even the SUPPORT interventiona robust, well‐implemented, and highly labor‐intensive strategywas not able to achieve this goal. In their summary of SUPPORT study findings, the authors suggested that the likelihood of and effectiveness of communication in seriously ill patients may be powerfully influenced by patient and caregiver culture4; our findings may partially confirm SUPPORT's conclusions.

Preexisting documentation in our study would not have included mandated documentation that someone had given the patient information about advance directives (as mandated by the PSDA), but rather a specification for that advance care plan. This distinction means that preexisting documentation in our study represented a previous decision by the patient (or the patient and their physician) to have made a plan, and an association with hospital discussions may be because the first conversation is the hardest to undertake; subsequent discussions then represent confirmatory or clarifying discussions that may be less difficult to broach (particularly for less experienced trainees). A CD may have also been prompted when documentation was unclear, or when a change in prognosis took place (eg, a new diagnosis of metastatic cancer).22 Alternatively, a preexisting plan may serve as a reminder for clinicians to discuss code status, signify patients who are more willing to broach this subject, and either seem more approachable or bring up the topic themselves.

The influence of site on documentation and CD provides additional evidence that caregiver culture played a role in CDs. Although this variation may have been in part due to culture around documentation practices more generally, it is important to note that none of our participating centers had a policy for documentation of care wishes or patient‐doctor communication, or a policy mandating these discussions in any specific patient group. Furthermore, site‐related differences were seen even in patients with no preexisting documentation, and were seen after adjustment for other documentation or communication practices (eg, documenting a discussion with the patient's primary care provider), making it unlikely that documentation practices are solely responsible for our results. Persistence of variations in care documentation raises interesting questions, particularly when one considers recent data describing variations in end‐of‐life care between similar academic centers (one of which was a participating site in this trial).23 Given that the sites in our study represent diverse institutions yet share a number of characteristics, understanding the specific practices or aspects of medical culture that promote conversations may provide insights in how to improve this promotion elsewhere.

Our results would argue that mandates to document code status on admission may be unlikely to improve communication unless sites also develop an approach to using this newly documented information as a prompt for subsequent discussions. In nursing home settings, documentation of advance directives may reduce resource use, but it is unclear whether similar effects will be seen in hospital settings.24 It is also a challenge to insure that documentation of a care plan in the nursing home is communicated to the providers in the hospital.25 The PSDA was a first step in this direction, but its effects on improving communication are uncertain.26 Our results would confirm that the PSDA or systems to mandate documentation are not solutions in themselves, but are 2 steps in a larger process.

We do not want to discount our findings of less frequent CDs among patients of lower socioeconomic status, where gaps in quality of care, communication, and outcomes are well‐recognized.27 As such, our results delineate yet another area where practice can and should be improved for vulnerable patients. However, factors related to site of care and documentation may provide opportunities to improve care even more profoundly and within a fairly discrete (if complex) acute episode of care. Having said this, our results also demonstrate a potential pitfall of using code status documentation for risk‐adjustment, because such notation may be more dependent on local documentation patterns than clinical appropriateness.

Our study has a number of limitations. As an observational study, our findings are likely prone to biases related to unadjusted confounding due to comorbidity. The influence of comorbidity would seem to have been most important in biasing the effects of preexisting documentation, where documentation would be associated with more unaccounted comorbidity. However, there were no differences in documentation even after accounting for prognosis by adjusting for age, functional status, and a valid comorbidity score.28 As we have pointed out, our key outcome is based on documentation of communication and not actual communication, and as such may be biased in subtle ways not related to site of care or the items tested in our model. While we cannot directly eliminate the possibility of documentation biases in our results using statistical methods, it is important to point out that our chart abstraction protocol used highly specific criteria to detect these discussions, and therefore may under‐detect discussions which may have been documented in less detail. Our study did not examine whether documentation of CDs influenced subsequent care. However, previous studies have shown that advance care planning has only a minor influence on care.29 However, communication about preferences at the time of admission, when the need for specific care decisions may be more evident, may be more likely to influence hospital care. Our results show that previous documentation is associated with discussions early in an admission. Such discussion may affect care, even if the decision made is different than what was previously documented. In addition, patients who were included in our study (those able to provide consent and participate in an interview) may be healthier or more cognitively intact than a general population of hospitalized patients. However, how this would have affected our results is unclear. Being able to speak and consent for oneself are key facilitators to communication, but sicker patients who cannot consent or speak for themselves might also be more likely to have care planning decisions made based on illness severity; documentation in these patients may be more driven by whether such notes were required because of the involvement of home health services (or skilled nursing facilities). Finally, although our study is one of the largest examinations of in‐hospital communication to date and its implications for resident education are worth noting, the sites involved in the MCHS may not be representative of nonteaching hospitals, or community‐based teaching hospitals.

Our results suggest that, although comorbid illness and socioeconomic status play an important role in determining which patients receive CDs at the time of admission, these factors are substantially less powerful than preexisting documentation practices and culture or care practices specific to their site of care. These results suggest that future work should consider organizational characteristics and culture as important targets for interventions to improve care planning in hospitalized patients.