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Original Research: CRITICAL CARE |

Code Status Orders and Goals of Care in the Medical ICU

Thomas G. Gehlbach, MD; Laura A. Shinkunas, BA; Valerie L. Forman-Hoffman, PhD, MPH; Karl W. Thomas, MD; Gregory A. Schmidt, MD, FCCP; Lauris C. Kaldjian, MD, PhD
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Drs Gehlbach, Thomas, and Schmidt) and the Program in Bioethics and Humanities (Ms Shinkunas and Dr Kaldjian), Division of General Internal Medicine (Drs Forman-Hoffman and Kaldjian), University of Iowa Carver College of Medicine, Iowa City, IA.

Correspondence to: Lauris C. Kaldjian, MD, PhD, Department of Internal Medicine, 1-106 MEB, University of Iowa Carver College of Medicine, 500 Newton Rd, Iowa City, IA 52242; e-mail: lauris-kaldjian@uiowa.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

Funding/Support: Dr Gehlbach was supported by a Ruth L. Kirschstein National Research Service Award [5 T32 HL 07638-22].


© 2011 American College of Chest Physicians


Chest. 2011;139(4):802-809. doi:10.1378/chest.10-1798
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Background:  Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care.

Methods:  We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders.

Results:  Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents’ average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status (P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care.

Conclusions:  Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients’ code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.

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