Rutgers Health researchers seek to reduce barriers to physicians having code status conversations with older adults

Adults 65 and older, who were hospitalized for a variety of medical conditions, had highly satisfying conversations about whether they wanted CPR, regardless of whether doctors used the terms “allow a natural death” or “do not resuscitate” for indicating no CPR, according to a pilot study by Rutgers Health researchers.

The study, published in the Journal of the American Geriatrics Society, sought to determine the best language doctors could use when discussing a patient’s code status to reduce the barrier to having these conversations. It found that it takes less than five minutes on average for doctors to have discussions going over what CPR is, what a patient’s preference might be and making a decision that patients felt comfortable with regarding whether they want to be resuscitated, according to the study.

This finding counters a perceived obstacle physicians have in engaging in this discussion with patients. Physicians are sometimes reticent to discuss patients’ wish for resuscitation in the event their heart stopped beating or they stopped breathing because of the length of time it takes to deliver such complex communication in a time-sensitive, stressful environment and out of concern for confusing or scaring the patients.

“There is an active debate about whether all patients need to be asked their code status when they are admitted to the hospital,” said Karthik J. Kota, an assistant professor of medicine and geriatrics at Rutgers Robert Wood Johnson Medical School and chair of the ethics committee at Robert Wood Johnson University Hospital New Brunswick. “Some experts recommend limiting the discussion to those at higher risk for potentially needing CPR.”

In the study, doctors read standardized resuscitation procedures using the terms “do not resuscitate (DNR)” and “allow a natural death” to 108 patients 65 and older, and then had a conversation about what the patient would want the medical team to do if their heart stopped. After the conversations, which were timed, patients were surveyed about how well they understood and felt about the discussion.  

“While the study did not clearly establish the doctors’ use of the term ‘allow a natural death’ as a better alternative to ‘do not resuscitate’ in regard to how informed patients felt about the decision they were making, it did provide evidence against two noted barriers to having the conversation by showing that the discussions were short less than five minutes on average and highly satisfactory to participants,” Kota said.  “More than 90 percent were satisfied by the discussion. This tells us that barriers may not be as prevalent as previously feared and that physicians should ask all patients their code status regardless of phrasing used.”

The study, which found 83 percent wished to be resuscitated, is the first to report on the resuscitation preferences for general inpatients older than age 65. By comparison, a 1992 survey of an outpatient geriatric practice found that 41 percent preferred CPR. The Rutgers Health study also established that 17 percent of the older hospitalized adults had no code preference, which the researchers said will be used to inform larger studies.