Arpagaus Armon, Arpagaus Leta, Becker Christoph, Gross Sebastian, Gössi Flavio, Bissmann Benjamin, Kaspar Zumbrunn Samuel, Schuetz Philipp, Leuppi Jörg D, Aujesky Drahomir, Hug Balthasar, Peters Thomas, Bassetti Stefano, Hunziker Sabina
Division of Medical Communication/Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland.
Division of Internal Medicine, University Hospital Basel, Basel, Switzerland.
JAMA Netw Open. 2025 Sep 2;8(9):e2533638. doi: 10.1001/jamanetworkopen.2025.33638.
Code status discussions represent a fundamental aspect of advanced care planning and impose major challenges for clinicians in patients for whom cardiopulmonary resuscitation (CPR) is considered futile.
To investigate the effect of a structured communication approach in code status discussions on decisions regarding code status and various quality-of-care measures for patients in whom resuscitation is considered futile.
DESIGN, SETTING, AND PARTICIPANTS: The GUIDE trial is a multicenter randomized clinical trial, which included patients deemed futile regarding CPR measures. The study was conducted between June 1, 2019, and April 30, 2023, in medical inpatients wards across 6 Swiss teaching hospitals. Medical inpatients for whom CPR measures were considered futile based on a prearrest Good Outcome Following Attempted Resuscitation score of 14 or higher or a Clinical Frailty Scale score of 7 or higher were eligible. Patients with cognitive or physical condition hindering meaningful conversation were excluded.
Main outcomes included patients' code status decisions as well as preference for mechanical ventilatory assistance and intensive care unit admission. Additional outcomes assessed patients' psychological burden after the discussion measured by the State-Trait Anxiety Inventory and Hospital Anxiety and Depression scale and physicians' perception regarding the discussions.
A total of 177 patients (mean [SD] age, 76.3 [12.0] years; 90 [51%] female) were studied. Overall, the rate of do-not-resuscitate orders was 85%. No significant difference was observed between groups (checklist vs usual care group, 79 of 89 [89%] vs 72 of 88 [82%]; odds ratio, 1.76; 95% CI, 0.75-4.12; P = .20). However, patients in the checklist group were less likely to prefer intensive care unit admission compared with usual care (31 of 89 [36%] vs 44 of 88 [52%]; odds ratio, 0.53; 95% CI, 0.29-0.99; P = .046). Physicians perceived code status discussions using the checklist less challenging (mean [SD], 3.5 [2.8] vs 4.7 [2.8]; difference, -1.23; 95% CI, -2.1 to -0.35; P = .006). There was no significant difference in patients' psychological reaction to code status discussions measured by State-Trait Anxiety Inventory and Hospital Anxiety and Depression scale.
This analysis of a randomized clinical trial found that checklist-guided code status discussions in patients for whom CPR was considered futile reduced their preference for intensive care unit admission while alleviating physicians' challenges during code status discussions without adversely affecting patients' psychosocial burden.
ClinicalTrials.gov Identifier: NCT03872154.
代码状态讨论是高级护理计划的一个基本方面，对于那些被认为心肺复苏（CPR）徒劳的患者，给临床医生带来了重大挑战。
探讨结构化沟通方法在代码状态讨论中对被认为复苏徒劳的患者的代码状态决策和各种护理质量措施的影响。
设计、设置和参与者：GUIDE试验是一项多中心随机临床试验，纳入了被认为CPR措施徒劳的患者。该研究于2019年6月1日至2023年4月30日在瑞士6家教学医院的内科住院病房进行。根据复苏尝试后良好结局评分14分或更高或临床衰弱量表评分7分或更高，被认为CPR措施徒劳的内科住院患者符合条件。因认知或身体状况妨碍有意义对话的患者被排除。
主要结局包括患者的代码状态决策以及对机械通气辅助和重症监护病房入院的偏好。额外结局评估了通过状态-特质焦虑量表和医院焦虑抑郁量表测量的讨论后患者的心理负担以及医生对讨论的看法。
共研究了177例患者（平均[标准差]年龄，76.3[12.0]岁；90例[51%]为女性）。总体而言，不进行心肺复苏医嘱的比例为85%。两组之间未观察到显著差异（清单组与常规护理组，89例中的79例[89%]对88例中的72例[82%]；优势比，1.76；95%置信区间，0.75 - 4.12；P = 0.20）。然而，与常规护理相比，清单组患者更不愿意入住重症监护病房（89例中的31例[36%]对88例中的44例[52%]；优势比，0.53；95%置信区间，0.29 - 0.99；P = 0.046）。医生认为使用清单进行代码状态讨论的挑战性较小（平均[标准差]，3.5[2.8]对4.7[2.8]；差异，-1.23；95%置信区间，-2.1至-0.35；P = 0.006）。通过状态-特质焦虑量表和医院焦虑抑郁量表测量，患者对代码状态讨论的心理反应没有显著差异。
这项对随机临床试验的分析发现，在被认为CPR徒劳的患者中，清单引导的代码状态讨论降低了他们对入住重症监护病房的偏好，同时减轻了医生在代码状态讨论期间的挑战，且未对患者的心理社会负担产生不利影响。
ClinicalTrials.gov标识符：NCT03872154。
