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Implementation of code status discussion early in the course of treatment for oncology patients.

88 Background: Having a code status discussion early in the treatment course of patients with advanced stage cancer is important to ensure that patients make decisions about life sustaining treatment in a non-urgent setting. There was not a standardized approach to addressing the code status of patients with stage IV cancer enrolled on the Supportive Oncology (SO) Pathway at Dana Farber Cancer Institute/South Shore. We addressed this problem by implementing a standardized method of documenting code status at or before the 3rd visit in patients with stage IV disease participating in our SO pathway.


METHODS
A process map highlighted that most patients with advanced cancer discussed their code status the day of hospice enrollment. A fishbone chart detailed the barriers to obtaining code status, and a priority pay-off matrix identified opportunities for improvement, including standardizing the process of the code status discussion and emphasizing the importance of the discussion early in the course of treatment. Physicians were educated on the importance of code status discussions and agreed that documentation should occur by the 3rd visit. Patients enrolled on the SO Pathway were tracked for the first three visits after initial referral to the pathway. We developed a script to assist physicians with code status discussions, which was placed on the encounter form at these visits. To measure the number of discussions, patient charts were reviewed on a weekly basis for documentation of code status.


RESULTS
Pre-intervention, during a 1 year period, only 14% (n=42) of patients enrolled on the SO pathway had a code status documented by the 3rd visit. After a 6 week implementation period, 70% (n=10) of patients enrolled on the SO Pathway had a code status documented in the chart by the 3rd visit.


CONCLUSIONS
Substantial improvement in code status documentation was seen post-implementation of our intervention. We conclude that a script/reminder is a useful tool to prompt physicians to have a meaningful code status discussion in a non-urgent setting. This project has made the often difficult process of obtaining code status a more standardized process, and a more integral part of the culture at the Cancer Center.