(897) Code Conversations in the Pediatric Intensive Care Unit

Introduction: Conversations about code status are an essential component of end-of-life care. In pediatrics, there is a lack of standardization regarding if, when, and how these conversations occur. Keele et al. estimated code discussions happen with ~2.5% of Pediatric Intensive Care Unit (PICU) patients. Single institution studies exist describing physician practices in code discussions, but no multiple institution studies. Our study aimed to identify patterns in code conversation practices in PICUs around the US.

Methods: We designed a survey to assess factors that influence physicians' decision to have a code conversation, patient populations with whom physicians always have code conversations, and current practices in code discussions. This survey was distributed to fellow and attending physicians through PICU fellowship program directors and the American Academy of Pediatrics Section on Critical Care listservs.

Results: We received 186 responses from attending (139/186, 75%) and fellow (47/186, 25%) physicians in pediatric critical care. Most respondents, (96/188, 59%) report having code conversations with less than 20% of patients; however, 40% (64/161) of respondents identified patient population(s) with whom they always have a code conversation. Most respondents say they always discuss code status when a patient has existing outpatient directives (118/159, 74.2%), previous DNR order (115/162, 71%), or family members asking questions about end-of-life care (107/162, 66%). Most respondents indicate they avoid conversations always or most of the time when a patient’s diagnosis is unlikely to lead to decompensation during admission (123/161,76.4%) or if patient’s diagnosis is not likely to be life-limiting (134/161, 83.2%). Most respondents report they never avoid code discussions due to lack of training in code discussions (138/159, 86.8%), lack of personal comfort with code discussions (130/160, 81.2%), or existing directives as an outpatient (117/159, 73.6%). There is little difference between the practices of fellow and attending physicians.

Conclusions: Code discussions occur for a minority of PICU patients. Our results confirm that code discussion practice varies among physicians and provide a foundation for future standardization efforts to improve end-of-life care for PICU patients.