Association of Communication Interventions to Discuss Code Status With Patient Decisions for Do-Not-Resuscitate Orders: A Systematic Review and Meta-analysis

IMPORTANCE: Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary resuscitation (CPR) remains unclear. OBJECTIVE: To conduct a systematic review and meta-analysis regarding the association of communication interventions with patient decisions and knowledge about CPR. DATA SOURCES: PubMed, Embase, PsycINFO, and CINAHL were systematically searched from the inception of each database to November 19, 2018. STUDY SELECTION: Randomized clinical trials focusing on interventions to facilitate code status discussions. Two independent reviewers performed the data extraction and assessed risk of bias using the Cochrane Risk of Bias Tool. Data were pooled using a fixed-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. DATA EXTRACTION AND SYNTHESIS: The study was performed according to the PRISMA guidelines. MAIN OUTCOMES AND MEASURES: The primary outcome was patient preference for CPR, and the key secondary outcome was patient knowledge regarding life-sustaining treatment. RESULTS: Fifteen randomized clinical trials (2405 patients) were included in the qualitative synthesis, 11 trials (1463 patients) were included for the quantitative synthesis of the primary end point, and 5 trials (652 patients) were included for the secondary end point. Communication interventions were significantly associated with a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). In a preplanned subgroup analysis, studies using resuscitation videos as decision aids compared with other interventions showed a stronger decrease in preference for life-sustaining treatment (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Also, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55; 95% CI, 0.39-0.71). CONCLUSIONS AND RELEVANCE: Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions.