“If your heart stops…” - Physicians’ approaches in discussing code status with geriatric patients
A. C. Sterie1, E. Rubli Truchard2, R. J. Jox2 (1Lausanne ; 2CHUV)
According to international standards, physicians are required to document whether cardio-pulmonary resuscitation (CPR) is medically indicated and desired by hospitalized geriatric patients. Studies show that physicians find it more distressing than patients to talk about code status (Heyland et al. 2006, Sulmasy et al. 2008). Nevertheless, scant research exists regarding how CPR conversations are actually conducted, in particular when advanced age and multimorbidity challenge the prospects of a successful procedure.
We aim to gain an authentic insight into how CPR discussions between physicians and geriatric/palliative patients occur on hospital admission.
In a multi-method qualitative study, we collected 43 audio-recordings of patient-physician CPR discussions on admission to a Swiss rehabilitation facility for geriatric and palliative care patients. Conversation and Thematic Analysis are used to analyze the content of the conversations.
Initial analysis focusses on how physicians initiate the discussion about CPR. At the very beginning, physicians introduce the topic of CPR tentatively, using a depersonalized question (“we ask all our patients”), building on previous occasions in which such decision was discussed (“maybe you talked about this”). Physicians refer to the circumstances in which the decision regarding CPR would become relevant; such circumstances remain vague and their importance is often downplayed by reference to their hypothetical character (“if something serious were to happen”). Physicians then request the patient’s decision by referring, in more or less explicit ways, to the CPR procedure itself.
In a majority of cases, physicians do not provide prior information on the CPR procedure or the circumstances that make it relevant, nor on the patients’ recovery prognosis, benefits, burdens, and alternatives. This approach to launching the topic of CPR conveys the assumption that the patient has already made a decision that s/he is now asked to convey; in doing so, physicians fail to offer the patient an opportunity to take the decision on the spot or reassess it.
Appropriate communication is a core component of patient-centered healthcare, particularly when it comes to introducing sensitive matters to vulnerable populations such as geriatric and palliative patients. The results of the study inform on the training needs of physicians regarding how to approach and talk about sensitive issues such as CPR with aged patients who may also be seriously ill or in palliative condition.