Chapter 6 130 A similar approach was observed in an oncology outpatient department study, wherein a comprehensive strategy involving the Serious Illness Conversation Guide,28 provision of patient and family information materials pre and postconversation, clinician training, and system changes resulted in increased, earlier, and superior documented serious illness conversations.29 The intervention, with slight modifications, was later applied in a study involving patients hospitalized for at least 48 hours, yielding comparable outcomes.30 Another study also indicated that physician training increased care decisions in the electronic medical record (EMR).31 While these last two studies align closely with our study in terms of population and intervention, they didn’t measure for patient satisfaction or quality of communication. One of our secondary endpoints, the number of (patient-reported) code status discussions, indicated that prior to the intervention, code status was discussed in 46% of patients, compared to 64% after the implementation of the intervention. Noteworthy, in a previous study we observed that the registration of a code status in hospitalized patients in our hospital was 70%-73% 18, which is more than the 46%-64% of (patient-reported) code status discussions. This discrepancy between the documented code status, and patients memory of what was discussed and registered, was found in other Dutch hospitals as well.19 This could either mean code statuses are registered without discussion, or the patient does not recall the discussion. Ma et al. demonstrated that code status documentation (DNR) did not increase post-intervention (76% versus 71%). However, choices regarding life-sustaining treatments in general were noted much more frequently (67% versus 32%).30 High health literacy emerged as an important factor in achieving highquality care decisions. However, the optimal means of achieving this remains uncertain. Some studies have looked into video-assisted interventions, which proved to be a viable option.32 In our study, we chose to provide an information letter because of practical reasons in the emergency department. Remarkably, our study uncovered that a mere 12% of patients reported receiving the information letter. One plausible explanation could be the heightened workload experienced by physicians during our study period due to the COVID-19 pandemic, rendering it a low priority.
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