Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19

Whitney A Kiker¹, Si Cheng², Lauren R Pollack³, Claire J Creutzfeldt⁴, Erin K Kross³, J Randall Curtis³, Katherine A Belden⁵, Roman Melamed⁶, Donna Lee Armaignac⁷, Smith F Heavner⁸, Amy B Christie⁹, Valerie M Banner-Goodspeed¹⁰, Ashish K Khanna¹¹, Uluhan Sili¹², Harry L Anderson 3rd¹³, Vishakha Kumar¹⁴, Allan Walkey¹⁵, Rahul Kashyap¹⁶, Ognjen Gajic¹⁶, Juan Pablo Domecq¹⁷, Nita Khandelwal¹⁸; Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS): COVID-19 Registry Investigator Group

Affiliations

¹ Division of Pulmonary, Critical Care and Sleep Medicine (W.A.K., L.R.P., E.K.K., J.R.C., ), University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA. Electronic address: wkiker@uw.edu.
² Department of Biostatistics (S.C.), University of Washington, Seattle, WA, USA.
³ Division of Pulmonary, Critical Care and Sleep Medicine (W.A.K., L.R.P., E.K.K., J.R.C., ), University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA.
⁴ Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA; Department of Neurology, Harborview Medical Center (C.J.C.), University of Washington, Seattle, WA, USA.
⁵ Division of Infectious Diseases (K.A.B.), Thomas Jefferson University Hospital, Philadelphia, PA, USA.
⁶ Abbott Northwestern Hospital (R.M.), Allina Health, Minneapolis, MN, USA.
⁷ Center for Advanced Analytics (D.L.A.), Baptist Health South Florida, Miami, FL, USA.
⁸ Department of Public Health Sciences (S.F.H.), Clemson University, Clemson, SC, USA.
⁹ Department of Critical Care (A.B.C.), Atrium Health Navicent, Macon, GA, USA.
¹⁰ Department of Anesthesia, Critical Care & Pain Medicine (V.M.B-G.), Beth Israel Deaconess Medical Center, Boston, MA, USA.
¹¹ Department of Anesthesiology, Section on Critical Care Medicine (A.K.K.), Perioperative Outcomes and Informatics Collaborative (POIC), Wake Forest School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA; Outcomes Research Consortium (A.K.K.), Cleveland, OH, USA.
¹² Department of Infectious Diseases and Clinical Microbiology, School of Medicine (U.S.), Marmara University, Istanbul, Turkey.
¹³ Department of Surgery (H.L.A.), St Joseph Mercy Ann Arbor, Ann Arbor, MI, USA.
¹⁴ Society of Critical Medicine (V.K.), Mount Prospect, IL, USA.
¹⁵ The Pulmonary Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, and Evans Center of Implementation and Improvement Sciences, Department of Medicine (A.W.), Boston University School of Medicine, Boston, MA, USA.
¹⁶ Division of Pulmonary and Critical Care Medicine (R.K., O.G.), Mayo Clinic, Rochester, MN, USA.
¹⁷ Division of Nephrology and Hypertension (J.P.D.), Mayo Clinic, Rochester, MN, USA; Department of Critical Care Medicine (J.P.D.), Mayo Clinic, Mankato, MN, USA.
¹⁸ Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine (N.K.), University of Washington, Seattle, WA, USA.

PMID: 35764202
PMCID: PMC9233554
DOI: 10.1016/j.jpainsymman.2022.06.014

Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19

Whitney A Kiker et al. J Pain Symptom Manage. 2022 Oct.

. 2022 Oct;64(4):359-369.

doi: 10.1016/j.jpainsymman.2022.06.014. Epub 2022 Jun 25.

Authors

Affiliations

¹ Division of Pulmonary, Critical Care and Sleep Medicine (W.A.K., L.R.P., E.K.K., J.R.C., ), University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA. Electronic address: wkiker@uw.edu.
² Department of Biostatistics (S.C.), University of Washington, Seattle, WA, USA.
³ Division of Pulmonary, Critical Care and Sleep Medicine (W.A.K., L.R.P., E.K.K., J.R.C., ), University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA.
⁴ Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA; Department of Neurology, Harborview Medical Center (C.J.C.), University of Washington, Seattle, WA, USA.
⁵ Division of Infectious Diseases (K.A.B.), Thomas Jefferson University Hospital, Philadelphia, PA, USA.
⁶ Abbott Northwestern Hospital (R.M.), Allina Health, Minneapolis, MN, USA.
⁷ Center for Advanced Analytics (D.L.A.), Baptist Health South Florida, Miami, FL, USA.
⁸ Department of Public Health Sciences (S.F.H.), Clemson University, Clemson, SC, USA.
⁹ Department of Critical Care (A.B.C.), Atrium Health Navicent, Macon, GA, USA.
¹⁰ Department of Anesthesia, Critical Care & Pain Medicine (V.M.B-G.), Beth Israel Deaconess Medical Center, Boston, MA, USA.
¹¹ Department of Anesthesiology, Section on Critical Care Medicine (A.K.K.), Perioperative Outcomes and Informatics Collaborative (POIC), Wake Forest School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA; Outcomes Research Consortium (A.K.K.), Cleveland, OH, USA.
¹² Department of Infectious Diseases and Clinical Microbiology, School of Medicine (U.S.), Marmara University, Istanbul, Turkey.
¹³ Department of Surgery (H.L.A.), St Joseph Mercy Ann Arbor, Ann Arbor, MI, USA.
¹⁴ Society of Critical Medicine (V.K.), Mount Prospect, IL, USA.
¹⁵ The Pulmonary Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, and Evans Center of Implementation and Improvement Sciences, Department of Medicine (A.W.), Boston University School of Medicine, Boston, MA, USA.
¹⁶ Division of Pulmonary and Critical Care Medicine (R.K., O.G.), Mayo Clinic, Rochester, MN, USA.
¹⁷ Division of Nephrology and Hypertension (J.P.D.), Mayo Clinic, Rochester, MN, USA; Department of Critical Care Medicine (J.P.D.), Mayo Clinic, Mankato, MN, USA.
¹⁸ Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine (N.K.), University of Washington, Seattle, WA, USA.

PMID: 35764202
PMCID: PMC9233554
DOI: 10.1016/j.jpainsymman.2022.06.014

Abstract

Context: The COVID-19 pandemic has highlighted variability in intensity of care. We aimed to characterize intensity of care among hospitalized patients with COVID-19.

Objectives: Examine the prevalence and predictors of admission code status, palliative care consultation, comfort-measures-only orders, and cardiopulmonary resuscitation (CPR) among patients hospitalized with COVID-19.

Methods: This cross-sectional study examined data from an international registry of hospitalized patients with COVID-19. A proportional odds model evaluated predictors of more aggressive code status (i.e., Full Code) vs. less (i.e., Do Not Resuscitate, DNR). Among decedents, logistic regression was used to identify predictors of palliative care consultation, comfort measures only, and CPR at time of death.

Results: We included 29,923 patients across 179 sites. Among those with admission code status documented, Full Code was selected by 90% (n = 15,273). Adjusting for site, Full Code was more likely for patients who were of Black or Asian race (ORs 1.82, 95% CIs 1.5-2.19; 1.78, 1.15-3.09 respectively, relative to White race), Hispanic ethnicity (OR 1.89, CI 1.35-2.32), and male sex (OR 1.16, CI 1.0-1.33). Of the 4951 decedents, 29% received palliative care consultation, 59% transitioned to comfort measures only, and 29% received CPR, with non-White racial and ethnic groups less likely to receive comfort measures only and more likely to receive CPR.

Conclusion: In this international cohort of patients with COVID-19, Full Code was the initial code status in the majority, and more likely among patients who were Black or Asian race, Hispanic ethnicity or male. These results provide direction for future studies to improve these disparities in care.

Keywords: COVID; End of life; Palliative care.

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Figures

Fig 1 — **Fig. 1**
Odds from multivariate analyses of selecting a more aggressive code status order by patient characteristic.

Fig 2 — **Fig. 2**
Odds from multivariate analyses of receiving a palliative care consultation by patient characteristic.

Fig 3 — **Fig. 3**
Odds from multivariate analyses of receiving CMO by patient characteristic.

Fig 4 — **Fig. 4**
Odds from multivariate analyses of receiving CPR by patient characteristic.

See this image and copyright information in PMC

References

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Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19

Affiliations

Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19

Authors

Affiliations

Abstract

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References

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Full Text Sources

Medical