Code Status Orders in Patients Admitted to the Intensive Care Unit Due to Coronavirus Disease 2019

Abstract

RATIONALE: Patients with coronavirus disease 2019 (COVID-19) are frequently admitted to the intensive care unit (ICU) where goals of care conversations may result in changes in code status. Previous work has described how changes in code status in ICU patients influence objective measures like length of stay and mortality and the subjective experiences of patients and surrogates. To date, no study has described the code statuses of ICU patients with COVID-19. METHODS: A retrospective cohort study was performed of all patients admitted to the ICU at three hospitals in Boston, Massachusetts confirmed to have COVID-19 by positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction test between March 11, 2020, and May 31, 2020. Differences in code status at admission were examined. Continuous variables are presented as median and interquartile range (IQR, 1st-3rd) and categorical variables are presented as numbers with percentages. The Mann-Whitney U test was performed for continuous variables and the chi-square test (or Fisher Exact, when appropriate) for categorical variables. RESULTS: A total of 459 patients were admitted to the ICU, of which 421 (91.7%) were Full Code. The median age differed significantly between patients who had a Do Not Resuscitate (DNR) order and those who were Full Code [80.5 (IQR 64-97) versus 62 (IQR 40-84), p < 0.001]. There were no differences in gender or BMI. At admission, sequential organ failure assessment (SOFA) and simplified acute physiology score (SAPS II) scores were significantly higher in patients with DNR orders (p = 0.028, p < 0.001 respectively). The median Pao2 / Fio2 ratio at admission was 163 (IQR 43-283) and did not differ between groups. Patients who had DNR orders were more likely to be non-Latinx (86.8% vs 50.4%, p < 0.001), white (81.6% vs 54.2%, p < 0.012), and English-speaking (78.9% vs 48.5%, p < 0.001). Patients admitted from a private home, rather than a facility, were significantly more likely to be Full Code (85.0% vs 36.8%, p < 0.001). CONCLUSIONS: In our cohort, patients with DNR orders at admission were older, white, and non-Latinx, consistent with prior research in general ICU populations. We further identified a significant relationship between primary language and code status. Due to the unique barriers to communication imposed by the COVID-19 pandemic, and pre-existing barriers to communication with patients with limited English proficiency, our results highlight the necessity of specific interventions to overcome these challenges.