By Stacey Kusterbeck
If medical students lack experience with code status discussions, they’re likely to be uncomfortable initiating these difficult conversations after entering clinical practice. “Or they may do so according to a ‘script’ that they have seen faculty physicians, residents, or their peers use. And if the script is not a good one, patients may get the wrong impression about what they are being asked,” says Kyle E. Karches, MD, PhD, associate professor of internal medicine and healthcare ethics at Saint Louis University.
The problem is that some clinicians simply ask a patient a question such as, “Do you want to be resuscitated or intubated for cardiac arrest or respiratory failure?” Patients tend to answer affirmatively, even if it conflicts with their previously stated preferences regarding code status. The underlying issue is that the question, without additional clarification, does not address the patient’s overall goals of care, says Karches.
One study indicated that when clinicians asked about intubation preferences immediately after discussing code status, patients interpreted the two questions as linked.1 Thus, patients did not understand that they needed to think about situations in which they might develop respiratory failure but not cardiac arrest. As a result, some of these patients had do not resuscitate (DNR) and do not intubate (DNI) orders entered into the chart, when in fact they only really wanted to be DNR — and would have wanted to be intubated for a potentially reversible problem such as pneumonia. “If students do not gain experience with these conversations, they may miss these nuances, causing harm to patients,” warns Karches.
Based on this concern, Karches and a colleague made changes to the ethics curriculum at Saint Louis University’s medical school. By the third year of medical school, students already have completed some rotations on the wards and have had some experience talking to patients. At that point, faculty give students a lecture on end-of-life care discussions, including how to discuss code status and hospice care. Several weeks later, students take an objective structured clinical examination, which requires them to conduct in-person discussions with standardized patients.
Faculty give the students a clinical scenario with detailed information on the “patients” and family. The students are given a prompt for what they should accomplish. One scenario involves a patient whose test results have just come back showing that he has leukemia, but the patient is unaware of the diagnosis. The prompt states: “Your task is to inform the patient of his new diagnosis and begin a conversation about his goals of care, including his end-of-life care preferences.”
Students then have 15 minutes to hold a conversation. The interactions are recorded, and a faculty member grades the video based on what the student says and whether the student demonstrated empathy. The faculty member also provides detailed feedback to the student about how to improve. “Faculty might criticize some of the word choices that students made and suggest alternatives,” says Karches. For example, faculty might advise students to avoid jargon such as “perfusion” and use terms such as “blood flow” instead. Faculty might offer feedback on body language, pointing out if the student failed to make good eye contact and instead looked at a clipboard. “They will also identify what the student did well and encourage the student to build on those skills,” says Karches.
Students must pass the exam to complete their third year. “We have received good comments from students and faculty about this experience. We believe it is contributing significantly to students’ learning,” says Karches.
Karches emphasizes to students that all physicians must know how to have these conversations with patients. “The only way to acquire skills is to practice them under the supervision of an expert. We developed our own curriculum for this reason,” says Karches.
Often, physicians focus on day-to-day clinical decisions, overlooking the bigger picture of patients’ goals and preferences. Those conversations happen only after the patient is too sick to fully participate, placing the burden on surrogate decision-makers. “This places a lot of stress on family members and clinicians alike,” says Karches.
Ideally, students become comfortable enough with code status conversations to initiate them routinely. Early discussions may prevent disagreements at the end of life about what the patient would have wanted. “It is certainly possible that this kind of curriculum might prevent some ethical conflicts. Even if this kind of practice has no measurable impact, however, we should require it anyway because it’s simply the right thing to do,” observes Karches.
Future physicians need time to develop authentic communication strategies to address morally and emotionally complex topics, says Margie Hodges Shaw, JD, PhD, HEC-C, director of clinical bioethics at the University of Rochester Medical Center. At the University of Rochester School of Medicine and Dentistry, students regularly participate in short simulation activities to practice talking from the perspective of a care provider, including, in year three, talking about death and dying. Some educational activities involve students taking turns playing different roles; others use actors from the standardized patients program. “It is critical to teach students how important these conversations are in patient care and how to prepare for them,” says Shaw.
Early in medical training, many students struggle with how to appropriately respond to grief, anger, and other powerful emotions. “Often, students want desperately to alleviate the suffering even when the scenario does not allow for a medical solution,” says Shaw.
Students receive communication training on how to identify, acknowledge, and respond to the emotions of patients and family members. “If doctors are trained to only respond to the words in a question, they may miss what is most important about the communication,” explains Shaw. Many students report that the training prepared them for conversations with patients during their third and fourth year.
Shaw explains to students that the term “goals of care” often is used as a euphemism to mean discussion about end-of-life decisions. “But goals of care are important to understand in all medical encounters,” says Shaw. For example, a patient may decide to delay a treatment to participate in an important personal or professional activity. “It is hard to trust a doctor who doesn’t know you. Empathy — and exquisite communication skills — can help doctors earn the trust necessary to really care for a patient,” concludes Shaw.
- Curtis JR, Mirarchi FL. The importance of clarity for hospital code status orders: Challenges and opportunities. Chest 2020;158:21-23.
