Dying for Advice: Code Status Discussions Between Resident Physicians and Patients with Advanced Cancer--A National Survey

Background: Patients with treatment-resistant advanced cancer rarely benefit from cardiopulmonary resuscitation (CPR) but infrequently discuss end-of-life care with physicians until hospitalized. Admitting resident physicians may conduct initial code status discussions, but may elicit patients' preferences without providing necessary guidance.

Objective: We surveyed residents' approach to code status discussions to identify barriers hindering informed decision making.

Methods: We developed an online case-based survey and enrolled subjects via e-mail requests to program directors. U.S. internal medicine residents (n=358; response rate 22.0%) from 19 programs participated. We measured respondents' likelihood of discussing prognosis and benefit of CPR, likelihood of offering code status recommendations, preference for discussing code status independent of attending physicians, and satisfaction with end-of-life discussions.

Results: Nearly all residents felt CPR would be unhelpful. Yet fewer than half (46.7%) were likely to discuss an estimate of prognosis and the value of CPR with the patient. Only 30% were likely to offer a recommendation on CPR. A majority (69%) of residents who were unwilling to offer a recommendation stated that deference to patient autonomy prevented them from providing guidance. Residents preferred to discuss code status independent of attendings, primarily due to a sense of responsibility. Ultimately, only a minority was satisfied with end-of-life discussions.

Conclusion: U.S. internal medicine resident physicians are unlikely to discuss prognosis or offer recommendations on CPR in treatment-refractory cancer principally because of a conflict with their concept of patient autonomy. Given the futility associated with CPR in this setting, these data define an unmet need in training and practice.