E-mail Reminders to Providers May Improve Documentation of Code Status in Patients with Advanced Disease 


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E-mail reminders to providers at the start of each new chemotherapy regimen may improve the rate and timing of code status documentation for patients with advanced lung cancer, according to a study in the Journal of Clinical Oncology. Jennifer S. Temel, MD, and colleagues from Massachusetts General Hospital in Boston reported the results of a two-phase study to “develop and assess the effect of electronic prompts to encourage oncology clinicians to document code status in the outpatient electronic health record of patients with advanced lung cancers.” 

First Phase

The first phase consisted of focus groups with oncology clinicians—one with physicians and one with nurses and nurse practitioners. The aim of the meetings was to explore knowledge and practice related to code status in patients with incurable malignancies as well as to assess perceptions about the delivery, content, timing, and acceptability of an electronic prompt to document code status. 

“Oncology clinicians reported that conversations with patients regarding their resuscitation preferences primarily occur in the inpatient setting or at times of clinical deterioration, although most agreed this was not the optimal timing because of the level of stress experienced by patients and families in those circumstances,” the authors wrote. 

“Four main themes emerged regarding the delivery, timing, content, and acceptability of an electronic prompt to encourage discussion and documentation of resuscitation preferences in the outpatient setting,” they continued. “Specifically, the prompts ideally should (1) be brief and delivered early in the course of disease, (2) identify clearly the relevant patient, (3) contain minimal clinical information, and (4) be sent close to the time of the patient’s clinic visit. Additionally, clinicians felt that e-mail reminders were more acceptable than a ‘pop-up’ on the [electronic health record] or a ‘hard stop’ that prevents clinicians from ordering chemotherapy and interferes with their workflow,” the researchers reported. “Informed by these themes, we developed two succinct e-mail prompts that were delivered in tandem with each new line of chemotherapy.”

Second Phase

In the second phase, clinical documentation of code status in the electronic health record of 100 patients with incurable lung cancer who agreed to participate in the study was compared to documentation of 100 consecutive historical controls who began therapy for incurable lung cancer at least 1 year before the start of the study. E-mail prompts were sent to the clinical team caring for the patient (physician, nurse practitioner, and oncology fellow). 

“The first e-mail prompt was sent on the morning of the outpatient appointment immediately after the visit at which the patient provided written informed consent for the study,” the investigators explained. “Subsequent e-mail prompts were sent on the day of the outpatient appointment immediately after the start of each new line of chemotherapy (either oral or IV) until a code status was documented in the [electronic health record] code status module or the patient was referred to hospice or died.”

At 1-year follow-up, 33 of 98 (33.7%) study participants had a code status documented in the outpatient electronic health record compared with 12 of 83 (14.5%) historical controls (P = .003), the researchers reported. The majority in both groups had a documented code status listed as DNR/DNI (do not resuscitate/do not intubate). “Mean time to code status documentation was significantly shorter” among the study participants: 8.6 vs 10.5 months for controls (P = .004). 

Deferring or delaying conversations about preferences for end-of-life care “has negative implications both for patients with cancer and society as a whole,” the authors wrote. “Specifically, patients with advanced cancer who do not recall discussing their [end-of-life] care goals are significantly more likely to receive aggressive medical care, initiate hospice services later in the course of disease, and lack a documented code status. Alternatively, patients who report having these conversations have significantly lower health-care costs in the final week of life, when the majority of health-care expenditures occur.” 

‘Long Way to Go’

The results of the study represent an improvement, “but we still have a long way to go,” wrote Jamie H. Von Roenn, MD, of Feinberg School of Medicine, Northwestern University, Chicago, in an editorial accompanying the article. “Because we all tend to do what is most comfortable on the basis of our training, it is not surprising that many oncologists prefer to delay the often difficult conversations regarding code status or hospice care until there are no nonpalliative treatment options remaining,” she added. “A systematic review and meta-analysis of the efficacy of communication skills training in oncology concluded that skills training is a promising approach to change this communication behavior. This training is essential.” ■

Temel JS, et al: J Clin Oncol January 2, 2013 (early release online).

Von Roenn, JH: J Clin Oncol January 2, 2013 (early release online). 



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