Inadequate understanding of code status improved by case-based learning

There is limited literature on whether providers have an adequate understanding of DNR/DNI. Our study evaluates the understanding of DNR/DNI among physicians in training and the efficacy of case-based learning in code status education.

In Fall 2011, we surveyed medical students and residents at Yale School of Medicine before and after a case-based end-of-life course constructed using the same standards as the nationally utilized Yale Office-Based Medicine Curriculum. Mcnemar test was used to evaluate changes in responses.

Of 44 surveys, in DNR patients with cardiopulmonary arrest in which no interventions should be performed, some participants would provide chest compression (before=9%, after=7%), defibrillation (before=7%, after=7%), epinephrine (before=32%, after=25%), antiarrhythmics (before=50%, after=32%), bicarbonate (before=61%, after=48%), ambu-bag (before=48%, after=59%), and intubation (before=59%, after=50%). In DNI patients, some participants failed to offer ambu-bag (before=64%, after=86%) and non-invasive positive pressure ventilation (before=91%, after=93%).

After the course, participants were 9 times more likely to correctly forego amiodarone in coding DNR patients (p=0.02), and 11 times more likely to correctly offer ambu-bag in DNI patients (p=0.01). When asked if participants possess adequate understanding of DNR/DNI on a scale of 1 (disagree) to 5 (agree), there was a 0.93 point increase after the course (before=3.26, after=4.19, p=0.00). Ninety-three percent would recommend the course to others.

Surveys showed inadequate understanding of DNR/DNI among providers that improved with case-based learning, resulting in appropriate decisions regarding end-of-life care. Providers may benefit from code status education, particularly case-based learning which may improve their understanding of DNR/DNI and the quality of end-of-life care.