Hospital and Temporal Variations in Limitations of Care Among Hospitalized Patients with COVID-19: A VIRUS Registry Retrospective Cohort Study

Nathan Mesfin¹, Nitesh Kumar Jain², Anwar Khedr², Hisham Mushtaq², Abbas B Jama², Noura Attallah², Esraa Hassan², Benjamin Langworthy³, Nicholas Ingraham¹, Juan Pablo Domecq Garces⁴, Thoyaja Koritala⁵, Donna Lee Armaignac⁶, Nicholas Eugene Perkins⁷, Katherine Belden⁸, Vishakha Kumar⁹, Karen Boman⁹, Devang K Sanghavi¹⁰, Vikas Bansal¹¹, Rahul Kashyap¹², Rodrigo Cartin-Ceba¹³, Abigail La Nou¹⁴, Allan J Walkey¹⁵, R Adams Dudley^{1

16}, Syed Anjum Khan²; Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS): Covid-19 Registry Investigator Group

Affiliations

¹ Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA.
² Division of Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA.
³ Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.
⁴ Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
⁵ Department of Hospital Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA.
⁶ Center for Advanced Analytics, Baptist Health South Florida, Coral Gables, Florida, USA.
⁷ Department of Hospital Medicine, Prisma Health, Greenville Memorial Hospital, Grenville, South Carolina, USA.
⁸ Department of Medicine, Division of Infectious Disease, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA.
⁹ VIRUS Registry, Society of Critical Care Medicine, Mount Prospect, Illinois, USA.
¹⁰ Department of Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA.
¹¹ Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
¹² Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
¹³ Division of Pulmonary Medicine, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA.
¹⁴ Department of Critical Care Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin, USA.
¹⁵ Pulmonary Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Evans Center of Implementation and Improvement Sciences, Boston, University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA.
¹⁶ Institute of Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA.

PMID: 41142473
PMCID: PMC12547400
DOI: 10.1177/26892820251380523

Hospital and Temporal Variations in Limitations of Care Among Hospitalized Patients with COVID-19: A VIRUS Registry Retrospective Cohort Study

Nathan Mesfin et al. Palliat Med Rep. 2025.

. 2025 Sep 25;6(1):468-473.

doi: 10.1177/26892820251380523. eCollection 2025.

Authors

Affiliations

¹ Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA.
² Division of Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA.
³ Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.
⁴ Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
⁵ Department of Hospital Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA.
⁶ Center for Advanced Analytics, Baptist Health South Florida, Coral Gables, Florida, USA.
⁷ Department of Hospital Medicine, Prisma Health, Greenville Memorial Hospital, Grenville, South Carolina, USA.
⁸ Department of Medicine, Division of Infectious Disease, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA.
⁹ VIRUS Registry, Society of Critical Care Medicine, Mount Prospect, Illinois, USA.
¹⁰ Department of Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA.
¹¹ Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
¹² Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
¹³ Division of Pulmonary Medicine, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA.
¹⁴ Department of Critical Care Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin, USA.
¹⁵ Pulmonary Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Evans Center of Implementation and Improvement Sciences, Boston, University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA.
¹⁶ Institute of Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA.

PMID: 41142473
PMCID: PMC12547400
DOI: 10.1177/26892820251380523

Abstract

Introduction: Life-support limits (i.e., code status), the first step in the continuum of palliation and end-of-life (EoL) care, stem from decisions made by patients and their providers to align care near the EoL with patients' wishes. The pandemic created health care strain that may have influenced life-support limitation practices among patients with serious COVID-19. In this study, we examine variations in life-support limitations (do-not-resuscitate, DNR; do-not-intubate, DNI) depending on the hospital and period of hospitalization.

Methods: We included all adults admitted to a hospital in the United States with COVID-19 from January 2020 to December 2021 using the VIRUS registry. Our outcome was any life-support limitation on admission (DNR, DNI, or both) using regression modeling. Main exposures were hospital and period of hospitalization (early vs. late pandemic). Covariates included age, sex, race/ethnicity, comorbidities, and hospitalization diagnoses.

Results: There were 42,383 patients from 75 hospitals in the US. The median age was 63 (interquartile range: 50-75), 46.5% were female, and 37.5% were non-Hispanic White. The life-support limitation rate was 7.9%, and the palliative care consultation rate was 2.3%. The odds of life-support limitation were 1.86 (95% CI: 1.6-2.1) depending on the hospital, but the period of hospitalization was not associated with odds of life-support limitation. Older age was associated with the greatest increased odds (4.1 per standard deviation ∼ 17.9 years, 95% CI: 3.9-4.4), followed by comorbidities including paralysis (2.4, 95% CI: 1.8-3.0) and dementia (2.3, 95% CI: 2.0-2.6).

Conclusions: After adjusting for patient-level factors, we report significant inter-hospital but no temporal variation in life-support limitation upon admission with COVID-19. Future studies should investigate specific practices that led to health care resilience to temporal practice variations in life-support limitation during the pandemic.

Keywords: COVID-19; code status; do-not-resuscitate; life support care; withholding treatment.

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Figures

**FIG. 1.**
Flowchart for derivation of cohort for both hospital and temporal variation. The asterisk marks the point of missing data imputation.

**FIG. 2.**
Hospitals ranked in order of increasing adjusted admission life support limitation rate (n = 42,383, 75 hospitals). The adjusted covariates include demographics, comorbidities, and admission diagnoses.

See this image and copyright information in PMC

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Hospital and Temporal Variations in Limitations of Care Among Hospitalized Patients with COVID-19: A VIRUS Registry Retrospective Cohort Study

Affiliations

Hospital and Temporal Variations in Limitations of Care Among Hospitalized Patients with COVID-19: A VIRUS Registry Retrospective Cohort Study

Authors

Affiliations

Abstract

Figures

References

LinkOut - more resources

Full Text Sources