Department of Medicine, Stanford University, Stanford, California, USA
Department of Anesthesia, Stanford University, Stanford, California, USA.
BMJ Qual Saf. 2021 Aug;30(8):668-677. doi: 10.1136/bmjqs-2020-011222. Epub 2020 Oct 20.
US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied.
Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences.
The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital's code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories.
There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.
美国医院通常提供一套包括全面急救（Full Code）和不复苏（Do Not Resuscitate，DNR）在内的代码状态选项，但通常还包括其他选项。尽管美国医院在代码状态选项的设计上存在差异，但这种差异及其影响尚未经过实证研究。
在 7 家美国医院进行了多机构定性研究，这些医院在地理位置、机构类型和代码状态选项设计方面存在差异。我们通过三种数据源（政策文件、代码状态订购菜单和深入的医生访谈）进行三角交叉，以描述每家医院可用的代码状态选项。使用归纳定性方法，我们调查了医院代码状态选项的设计差异以及这些差异的感知影响。
每家医院的代码状态选项在代码状态选项的数量、代码状态选项的名称和定义以及代码状态订购菜单的格式和功能方面差异很大。DNR 订单在每家研究的医院中的命名和定义都不同。我们确定了五个关键的设计特征，这些特征影响代码状态订单的功能。每家医院的代码状态选项在这些特征方面都是独特的，这表明代码状态在每家医院中扮演着不同的角色。医生参与者认为，代码状态选项的设计塑造了关于复苏和生命支持治疗的沟通和决策实践，尤其是在生命末期。我们确定了四种潜在的机制，通过这些机制可能会发生这种情况：框架对话、提示决策、推断和创建类别。
医院代码状态选项的设计存在实质性差异，这可能导致美国医院在生命末期护理和治疗强度方面存在已知的差异。我们的框架可用于设计医院代码状态选项或评估其功能。
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