Association of code status discussion with invasive procedures among advanced-stage cancer and noncancer patients

Figures & data

Table 1 Presentations associated with a median survival of ≤6 months, with effect of treatments on survival

Terminal illness presentation
Cardiovascular disease, heart failure
Hospitalization for moderate-to-severe symptomatic heart failure, NYHA Class III or IV, with 3 or more of the following presentations:	Age >70 years
	Left ventricular ejection fraction ≤20%
	Serum B-type natriuretic peptide >950 pg/mL
	Cardiac troponin I >0.4 ng/mL
	C-reactive protein >3.5 mg/L
	Fourth hospitalization for heart failure or repeat hospitalization in 2 months
	Dependency of 3 or more activities of daily living or need for home care after hospital discharge
	Weight loss of ≥2.3 kg within 2 months or serum albumin <2.5 g/dL
	History of cardiogenic shock, ventricular or supraventricular arrhythmia, cardiac arrest, cardiopulmonary resuscitation, or mechanical ventilation
	Systolic blood pressure ≤110
	Serum creatinine >2 mg/dL or blood urea nitrogen >40 mg/dL
	Serum sodium <135 mEq/L
	Cardiovascular disease (ischemic, peripheral vascular, or cerebrovascular disease)
	Other comorbid illness (diabetes mellitus, dementia, chronic obstructive pulmonary disease, cirrhosis, and cancer)
Geriatric syndromes
Dementia
Advanced dementia with dependency in all activities of daily living, bedbound status, urinary and bowel incontinence, decreased ability to communicate verbally, and admission to a hospital or skilled nursing facility, with 1 or more of the following presentations:	Malnutrition (manifested by body mass index <18.5 kg/m^2, decreased oral intake, or significant weight loss)
	Presence of at least 1 pressure ulcer
	Evidence of at least 1 comorbid illness
	Male sex plus age >90 years
	Placement of a nasogastric or gastrostomy feeding tube, due to inability to eat or history of aspiration pneumonia
Geriatric failure to thrive
Age >75 years, serum albumin <3.5 g/dL, and dependency in ≥2 activities of daily living, with admission to an acute care hospital or skilled nursing facility and 1 or more of the following presentations:	Dependency in all activities of daily living with malnutrition (weight loss ≥10% of body weight or serum albumin <3 g/dL)
	Evidence of heart failure
	Serum creatinine >3 mg/dL
	Evidence of delirium during hospitalization
	Significant disability before hospitalization, with further functional decline posthospitalization
Hepatic disease
Cirrhosis
Decompensated hepatic cirrhosis and 1 or more of the following presentations:	Child–Pugh score ≥12
	MELD score ≥21
Decompensated hepatic cirrhosis with hospitalization for an acute illness related to liver disease and 1 or more of the following presentations:	Child–Pugh score ≥10
	MELD score ≥18
	Child–Pugh score ≥9 plus dependency in ≥3 activities of daily living and malnutrition (significant weight loss and albumin <2.5 g/dL)
	Hospitalization in an intensive care unit related to severe decompensation of liver disease, with hypotension requiring the use of pressors, serum creatinine >1.5 mg/dL, or evidence of jaundice
	Evidence of hepatopulmonary syndrome or rapidly progressive hepatorenal syndrome
Pulmonary disease COPD
Hospitalization for a severe COPD exacerbation, with hypoxemia (pO2 ≤55 mm Hg), hypercapnia (pCO2 ≥50 mm Hg), and supplemental oxygen dependence, with 3 or more of the following presentations:	Age >70 years
	Evidence of right-sided heart failure (cor pulmonale)
	Repeat hospitalization for COPD within 2 months
	History of intubation and mechanical ventilation
	Karnofsky performance status <60 or dependency of 3 or more activities of daily living before the hospitalization
	Need for home care after hospital discharge
	Malnutrition (weight loss of ≥2.3 kg, serum albumin <2.5 g/dL, or body mass index <18 kg/m^2)
	Serum creatinine >2 mg/dL
Renal disease
End-stage renal disease
End-stage renal disease on dialysis, with age >70 years and 2 or more of the following presentations:	Karnofsky performance status <50 or dependency in activities of daily living
	Significant comorbid condition such as coronary artery disease, peripheral vascular disease, heart failure, and cancer
	Malnutrition (body mass index <19.5 kg/m^2 or serum albumin <2.2 mg/dL)
	Residence in a skilled nursing facility
	Admission to an intensive care unit for an acute illness
	Hip fracture with inability to ambulate
End-stage renal disease without the use of dialysis, with age >70 years and 1 or more of the following presentations:	Dialysis withheld for those with decreased performance status and significant comorbidity
	Dialysis withdrawn due to advanced age, functional dependence, and comorbidity

Note: Reproduced from Am J Med, 125, Salpeter SR, Luo EJ, Malter DS, Stuart B, Systematic review of noncancer presentations with a median survival of 6 months or less, 512.e1–512.e6, Copyright (2012), with permission from Elsevier.⁹

Abbreviations: COPD, chronic obstructive pulmonary disease; MELD, Model of End-Stage Liver Disease; NYHA, New York Heart Association.

Table 2 Patient characteristics

Variables	Presence of code status discussion (n=115)	Absence of code status discussion (n=117)	P-value
Age, median (25th, 75th percentile)	82 (75, 88)	80 (74, 87)	0.294
Male, n (%)	68 (59)	63 (54)
Independent ADLs, n (%)	32 (28)	36 (31)	0.67
Comorbidities, n (%)
Heart failure	30 (26)	52 (44)	<0.01
Cerebrovascular disease	28 (24)	23 (20)	0.43
Chronic lung disease	19 (17)	31 (27)	0.079
Chronic kidney disease	25 (21)	20 (17)	0.409
Cancer	64 (55)	49 (42)	<0.05
Dementia	81 (70)	75 (64)	0.33
Primary diagnosisa, n (%)
Cancer	56 (49)	41 (35)	<0.05
Liver disease	6 (5.2)	8 (6.8)	0.78
Heart disease	5 (4.3)	19 (16.2)	<0.01
Renal disease	0 (0)	2 (1.7)	0.50
Cerebrovascular disease	3 (2.6)	0 (0)	0.12
Lung disease	6 (5.2)	20 (17.1)	<0.05
Geriatric syndrome or dementia	39 (33.9)	27 (23.1)	0.11

Note:

a Advanced stage of illness by which prognosis is estimated.

Abbreviation: ADLs, activities of daily livings.

Figure 1 Incidence of invasive procedures and cardiopulmonary resuscitation among cancer patients (A) and noncancer patients (B) in the presence and absence of code status discussion on admission.

Abbreviations: CPR, cardiopulmonary resuscitation; CV, central venous catheter placement; MV, intubation and mechanical ventilation.

Table 3 Factors associated with CPR

Factor	n	Incidence of CPR, n (%)	OR (95% CI) (adjusteda)
Age ≥75 years	173	23 (13)	0.75 (0.3–2.0)
Primary diagnosis
Cancer	97	9 (9)	0.42 (0.15–1.22)
Liver disease	15	4 (27)
Heart disease	24	6 (25)
Renal disease	2	1 (50)
Neurovascular disease	3	0 (0)
Respiratory disease	26	8 (31)	1.1 (0.34–3.43)
Geriatric syndrome or dementia	66	5 (8)	0.38 (0.11–1.28)
Presence of code status discussion on admission	115	1 (0.9)	0.03 (0.004–0.21)*

Notes:

a Adjusted for age ≥75 years; cancer, respiratory disease, or geriatric syndrome/dementia as a primary diagnosis; and absence of code status discussion on admission;

* P<0.001.

Abbreviations: CPR, cardiopulmonary resuscitation, OR, odds ratio.

SalpeterSRLuoEJMalterDSStuartBSystematic review of non-cancer presentations with a median survival of 6 months or lessAm J Med2012125512.e1512.e622030293

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