Code status orders in hospitalized patients with COVID-19

Area of Science:

• Medical Ethics
• Critical Care Medicine
• Public Health

Background:

• The COVID-19 pandemic presented significant ethical and clinical challenges regarding end-of-life care decisions.
• This includes the appropriate timing and utilization of do-not-attempt cardiopulmonary resuscitation (DNACPR) and Do Not Intubate (DNI) orders for hospitalized patients.

Purpose of the Study:

• To investigate the utilization patterns of DNACPR and/or DNI orders during different phases of the COVID-19 pandemic.
• To identify predictors, timing, and outcomes associated with these orders in COVID-19 patients.

Main Methods:

• A cohort study was conducted involving 1375 hospitalized COVID-19 patients across two Midwest hospitals.
• Data collected included demographics, laboratory results, treatments, clinical interventions, and outcomes (mortality, discharge disposition, hospice).
• Patients were categorized into early (March-October 2020) and late pandemic cohorts.

Main Results:

• 19% of patients had a documented DNACPR and/or DNI order.
• Older age and earlier hospitalization during the pandemic were associated with DNACPR orders.
• The time from DNACPR order to death was shorter in the early cohort (5 days) compared to the late cohort (2 days), though in-hospital mortality did not differ.

Conclusions:

• DNACPR/DNI orders were more prevalent and placed earlier in the hospital course for patients admitted early in the pandemic.
• Despite similar clinical characteristics and interventions, these changes may reflect pandemic-related factors like resource concerns and evolving knowledge.