Physician Perspectives on Challenges in Understanding Patient Preferences for Emergency Intubation: A Qualitative Assessment of Hospital Code Status Orders

Background Code status orders (eg, Do Not Resuscitate [DNR], Do Not Intubate [DNI]) are used to guide treatment in emergency scenarios when patient preferences cannot reliably be obtained. However, some code status orders (eg, partial code orders, combined DNR/DNI orders) have been criticized for lack of clarity regarding intubation. Research Question What are physician perspectives on the design of code status orders and their ability to clearly convey patient preferences regarding intubation in clinical emergencies? Study Design and Methods This was a qualitative study across seven purposively sampled US hospitals characterizing code status order designs through review of code status policy documents, code status ordering menus, and semi-structured physician interviews. Interviews were conducted with physicians from specialties that routinely interact with code status orders. Based on themes from interviews, criteria were generated to assess whether code status order designs effectively convey patient preferences for emergency intubation. Results Six order designs were identified that differed in their approach to emergency intubation. The designs differed primarily in how the resuscitation portion of the order (eg, DNR) was related to the intubation portion of the order (eg, DNI). Each design was assessed by using the criteria generated from interviews: (1) whether the orders differentiate intubation during CPR from intubation for pre-arrest respiratory failure; (2) whether the orders allow three options that physicians felt should be routinely offered (ie, Full Code, DNR/May Intubate, DNR/DNI); and (3) whether the orders prevent the option physicians felt should not be routinely offered (ie, Full Code but DNI). Only two order designs met all three criteria. Interpretation Some code status order designs create ambiguity for physicians about patient preferences for emergency intubation, placing patients at risk for unwanted intubation or failure to intubate in life-threatening scenarios. This study identified two order designs that hospitals can adopt to address this ambiguity.