Quantifying the Association Between Code Status Discussions and Outcomes in Critically Ill Older Adults Admitted to the Intensive Care Unit (ICU): A Retrospective Cohort Study
1
Department of Emergency Medicine, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada
2
Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada
3
Department of Medicine, NOSM University, Sault Ste. Marie, Ontario, ON P3E 2C6, Canada
*
Author to whom correspondence should be addressed.
Emerg. Care Med. 2025, 2(2), 16; https://doi.org/10.3390/ecm2020016
Submission received: 26 February 2025
/
Revised: 15 March 2025
/
Accepted: 26 March 2025
/
Published: 31 March 2025
Abstract
:Background: “Do Not Resuscitate” (DNR) status has been implicated as an independent risk factor for mortality in patients admitted to the ICU. The implications of DNR status in older, critically ill patients for whom these conversations are often most relevant are less known. Objective: To determine the relationship between code status and mortality in a subset of critically ill, older ICU patients. Methods: Retrospective cohort study of critically ill older adults as defined by an APACHE II score ≥20 and age ≥70, admitted to the ICU at a large community hospital in Ontario from 1 January 2013 to 31 December 2018. Results: Of 613 patients admitted to the ICU, 163 met the inclusion criteria. Of these, 64 (39.3%) had a DNR order, while the remaining 99 (60.7%) did not and were considered full code. We found a strong association between DNR status and mortality (OR 2.61; 95% CI 1.33 to 5.09). Patients with a DNR order stayed fewer days in the ICU (7.7 days (±3.6) vs. 9.9 days (±8.3)) and used fewer resources than similarly ill patients who were full code with no difference in discharge morbidity. Patients with a DNR order had lower average costs of hospital and ICU admissions in comparison to patients who were full code (CAD 49,589.10/pt. vs. CAD 59,704.70/pt. (Canadian dollars)). Conclusions: Among critically ill, older ICU patients, DNR status is strongly associated with in-hospital mortality. Those in the full code group used more resources, resulting in higher costs of hospitalization without any difference in discharge morbidity.
1. Background
Goals of care discussions to establish “code status” are often poorly approached by healthcare providers [1,2]. While informing patients about treatment options in the event of a cardiac arrest is important, many physicians feel uncomfortable approximating the risk of resuscitation without a full understanding of the nature and severity of a patient’s illness or personal factors like their religious views in the acute setting [3,4]. It is therefore not surprising that code status discussions are often omitted during hospitalization, resulting in “full code” status as the default strategy for most patients, which is not patient-centred [4].
A Do Not Resuscitate (DNR) order has been identified as an independent risk factor for mortality, as well as an indicator of a differential in care, including fewer interventions received [5,6]. This may suggest that code status discussions are being confounded with “do not treat: care plans” and may not be in keeping with patient wishes [5,6,7]. While studies have identified DNR status as a predictor of mortality, these conclusions were drawn from a heterogeneous patient population, including some as young as 18 years old for whom code status discussions are highly contextual [5,6,7]. Furthermore, DNR status has traditionally been studied as an all-or-none phenomenon, which might not be appropriate for seriously ill older adults who may have priorities beyond survival, such as ensuring functionality and comfort [5,6,7,8]. Thus, DNR status may not be an independent predictor of mortality in this population and may be more a result of poor underlying health status as demonstrated in the surgical literature [9].
We sought to examine the relationship between documented code status discussions and mortality in older ICU patients. As a secondary outcome, we analyzed the impact of an informed code status discussion on ICU resource utilization in this same group. Our primary focus was whether older ICU patients with a DNR order had different outcomes relative to similarly ill patients who were full code.
2. Methods
2.1. Study Design and Participants
This was a retrospective cohort study of older, critically ill patients admitted to the Sault Area Hospital (SAH) ICU between 1 January 2013 and 31 December 2018. The facility is a 289-bed community hospital in northern Ontario with a catchment area of 115,000 people, caring for approximately 500 ICU admissions per year. This study received approval from the joint Sault Area Hospital and Group Health Centre Research Ethics Board (REB2018–08–01).
We collected patient-level data at the time of admission to the ICU using the hospital’s electronic medical record (EMR). We included patients who were at least 70 years of age and critically ill, as defined by an Acute Physiology and Chronic Health Evaluation (APACHE) II score of ≥20 at the time of ICU admission. APACHE II scores were calculated on admission to the ICU and obtained from the (EMR). The APACHE II score includes 12 physiologic measurements including age and previous health status, and has been shown to provide a measure of disease severity that can predict outcomes in acutely ill patients [10].
2.2. Outcomes and Measures
Our primary objective was to compare in-hospital mortality between patients with a DNR and those deemed full code. A DNR order was defined as a medical directive on the chart indicating no cardiopulmonary resuscitation (CPR). In each case, DNR status was established either from the patient’s advanced directives (if sent from a continuing care facility) or during a family meeting within 72 h of ICU admission. Lacking such a definition, the remaining patients were deemed full code and assumed to be eligible for full resuscitative measures.
A secondary objective of this study was to compare resource utilization between patients with a DNR order and those without. While not included in the primary analysis, we recorded both the time to code status decision and any change in code status after 72 h. We collected details of the code status discussion noted in the medical record, including specific goals of care such as requests for non-invasive airway management, inotropic agents and vasopressors, dialysis, and requests for nutrition.
We ascertained resource utilization by comparing a variety of measures including length of ICU stay in days, length of total hospital stay in days, number and type of consultations obtained during hospitalization, and number of diagnostic images obtained during hospitalization. We estimated the cost of ICU and total hospital stay based on cost per hospital day using the Canadian Institute for Health Information combined with data provided by the Local Health Integrated Network (LHIN) [11,12]. The LHIN defines Sault Area Hospital as a large community hospital at which ICU care costs CAD 3639.00/day and hospitalization in a general ward costs CAD 1032.00/day [11,12].
2.3. Data Analysis
Continuous variables were expressed as mean ± standard deviation and categorical variables as counts and proportions. Univariate comparisons between code status groups were performed using Student’s t-test (parametric data) or Mann–Whitney U test (nonparametric data) for continuous variables and the chi-squared test for categorical data. Resource utilization patterns between DNR and full code groups were analyzed using the same principles. A Kaplan–Meier survival curve examined survival to hospital discharge between DNR and full code groups. The observation period for the survival analysis was set to the discharge date of the last patient who survived to capture all mortality. A separate survival analysis using Cox proportional hazards regression examined the association between time to a DNR order (in days) and hospital mortality.
3. Results
A total of 613 potential patients were identified over the 5-year study period, 163 of whom met the inclusion criteria. Of the 163 study patients, 64 (39.3%) had a DNR order, based on a documented conversation incorporating advanced directives within 72 h of admission. The remaining 99 (60.7%) patients were determined to be full code (Figure 1). The demographic characteristics of patients with a DNR order were similar to those who were full code (Table 1). The majority of patients in both groups were men, and the distribution of comorbidities and admitting diagnoses were comparable (Table 1).
We observed no significant difference in APACHE II scores between patients with a DNR order and those deemed full code (APACHE II score 23.7 vs. 24.4, respectively, p = 0.31) (Table 1). There was a statistically significant difference in age between groups, with those in the DNR group being somewhat older than those in the full code group (79.6 vs. 77.8, respectively, p < 0.05) (Table 1). Among those with a DNR order, 40.6% permitted non-invasive airway management, 10.9% permitted vasoactive agents, 6.3% permitted dialysis, 4.7% permitted feeding, and 43.8% requested exclusive measures focusing on comfort (Table 1). Among full code patients, 73.7% had no documented code status discussion and were assumed to be full code (Table 1).
Patients with a DNR order faced much higher mortality compared with those who were full code (46.9% vs. 25.3%) (Table 1). In the primary analysis, we observed a strong association between code status and in-hospital mortality (OR 2.61; 95% CI 1.32 to 5.09). Patients with a DNR order were less likely to survive to discharge in comparison to those who were full code (53.1% vs. 74.7%; OR 2.28; 95% CI 1.34 to 3.88; p = 0.0024) (Figure 2). As outlined in Figure 2, most of the survival differences between groups manifested during the first three weeks; thereafter, survival in both groups was relatively stable (Figure 2). Time to DNR order was not associated with mortality (HR 0.99; 95% CI 0.94, 1.04; p = 0.83).
Patients with DNR orders had significantly shorter lengths of stay in ICU (7.7 days vs. 9.9 days; p < 0.05) and received significantly fewer diagnostic images per patient than those who were full code (4.5 diagnostic images/pt. vs. 6.2 diagnostic images/pt.; p < 0.05) (Table 2). Patients with a DNR order had significantly more palliative care consults in comparison to the full code group (19% vs. 3.7% of all consultations; p < 0.05). Patients with a DNR order incurred lower ICU costs per stay, which was statistically significant, and lower total hospital costs per stay in comparison to those who were full code (CAD 28,020.30 vs. CAD 36,026.10, p < 0.05, and CAD 49,589.10 vs. CAD 59,704.70, p = 0.65, respectively) (Table 2) [11,12]. Patients with a DNR order used fewer resources than similarly ill patients who were full code with no difference in discharge morbidity (Table 3).
4. Discussion
We found that older ICU patients with DNR orders had higher hospital mortality, which is consistent with the literature reported among other populations and age groups [5,6,7,13,14,15]. While previous studies have found DNR status to be an independent predictor of mortality in all subjects, our study makes a different observation [5,6,7]. By exclusively focusing on older adults, a group generally characterized by greater comorbidity, we aimed to undertake a more targeted assessment of code status discussions and their relation to outcomes among a patient population who often have priorities beyond survival, such as ensuring functionality and comfort.
Although mortality was initially higher among patients with a DNR order, after approximately 3 weeks, there was no significant survival benefit in the full code group measured to the end of their hospital stay, suggesting overall mortality is related more to APACHE II score and pre-morbid illness rather than code status [7]. Of the patients deemed full code, the majority (73.7%) had no advanced directives or documented code status discussion, suggesting that there are frequent lapses in documenting goals of care consistent with the literature [4]. Interestingly, 23.2% of patients initially assumed to be full code were later categorized as DNR. Of these, 60.5% changed their status after a formal code status discussion, while 39.5% did so after continuous discussions with the ICU team. This underscores the importance of continually engaging patients and their families in these conversations, as it is expected that goals may change as the clinical course unfolds, especially when important clinical milestones are not achieved [16].
Our secondary analysis found that patients with a DNR order used significantly fewer resources compared to patients who were full code or opted for DNR status after the initial 72 h. These full code patients had prolonged hospital admissions but no survival benefit after the first 3 weeks. Based on guidelines for cost analysis derived from length of stay in ICU and general ward, this led to an estimated cost savings of CAD 10,000 per patient [11,12]. While some studies have analyzed mortality and cost savings in the ICU, as well as cost savings of palliative care conversations paired with code status discussions, no study has specifically placed a cost-saving value on an ICU-based code status discussion alone [15,17]. Our study demonstrated a cost benefit of having informed code status discussions and at the same time allowing patients the opportunity to express their wishes surrounding the escalation of care while conserving resources in those patients who feel an escalation of care would not be in keeping with their wishes, consistent with emergency medicine literature [18].
Additionally, while patients who were full code had longer hospital admissions than those with a DNR order, our study found no difference in patient discharge morbidity. Patients who survived hospitalization were discharged to similar environments with comparable functional status regardless of code status. Our findings are consistent with the literature stating that while patients with a DNR order have increased mortality, this is in the context of adhering to the patients’ goals of care and does not result in increased morbidity [4]. Morbidity among older, critically ill ICU patients appears to be based on admission illness severity (APACHE II) and is not correlated with code status, which again refutes the idea that patients with a DNR order receive worse care and consequently have worse outcomes.
Future studies should focus on how best to standardize code status discussions to encompass specific goals of care including airway management, use of vasoactive agents, dialysis, and wishes for palliative care involvement. Standardizing code status discussions to include these elements could be used to generate a prospective study analyzing the impact of a truly informed code status discussion on patient outcomes and resource utilization.
5. Limitations
The strengths of our study included a targeted approach to code status discussions and a focus on mortality among critically ill older patients. Some limitations of this study merit emphasis, including the small sample size, utilization of the APACHE II score to stratify illness, potential for selection bias, and potential for documentation bias given the retrospective nature of this study. With regards to the code status discussion, data were drawn retrospectively, and it was not always clear which individual conducted the code status discussion, what elements were included, and how the discussions were documented. Therefore, it cannot be ruled out that patients labelled as full code had an undocumented discussion. Our study set an arbitrary cut-off of 72 h in which to establish code status. There was a small group of patients whose status changed from full code to DNR more than 72 h after ICU admission, potentially increasing mortality among the group initially designated full code. Although the time to DNR order was not considered to be associated with mortality, these possible confounders may limit the generalizability and applicability of our results. This was a single-centre study, and the generalizability to other centres and patient populations is unknown. Finally, as with all observational studies, our study is hypothesis-generating and cannot infer causality.
6. Conclusions
In a population of older, critically ill patients, we found that a DNR order was associated with higher mortality and decreased resource utilization. Patients with a DNR order used fewer resources without any difference in discharge morbidity in comparison to patients who were full code. Code status discussions are a key component of providing high-quality, patient-centered care, which not only represents an opportunity to engage patients and their families in shared decision making but also to reduce hospital costs.
Author Contributions
This manuscript was a collaborative effort involving both authors equally. J.T.K.: conceptualization, methodology, writing—original draft, funding acquisition, project administration, investigation, formal analysis, writing—review and editing. R.G.: conceptualization methodology, writing—original draft, supervision, funding acquisition, project administration, investigation, formal analysis, writing—review and editing. All authors have read and agreed to the published version of the manuscript.
Funding
This research was funded through an XL Grant (<35,000) awarded on behalf of the Sault Ste. Marie Academic Medical Association (SSMAMA). SSMAMA had no part in the study design, conducting the study, or data analysis, and did not have any authority over these activities.
Institutional Review Board Statement
This study received approval from the joint Sault Area Hospital and Group Health Centre Research Ethics Board (approval code: REB2018–08–01; approval date: 20 August 2019).
Informed Consent Statement
Patient consent was waived due to the retrospective nature of the study as approved by the institutional REB.
Data Availability Statement
Data are housed in hospital records at Sault Area Hospital.
Acknowledgments
The authors would like to acknowledge and offer thanks to research assistant Erin Mulroney who assisted with data collection, Alex Kiss for statistical support, and David Juurlink for feedback on earlier versions of the manuscript.
Conflicts of Interest
The authors declare no conflict of interest.
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Figure 1.
Flowchart outlining methods used for patient inclusion in retrospective analysis.
Figure 2.
Kaplan–Meier survival curve to hospital discharge between DNR and full code patients.
Table 1.
Demographics of older ICU patients by code status.
| Independent Variable | Code Status | p-Value (<0.05) | |
|---|---|---|---|
| DNR (n = 64) | Full Code (n = 99) | ||
| Ages, years | |||
| Mean (SD) | 79.6 (±5.4) | 77.8 (±5.1) | <0.05 |
| Range | 71−93 | 71−94 | N/A |
| Sex (male), n (%) | 39 (60.9) | 58 (58.6) | 0.82 |
| APACHE Score Mean (SD) | 23.7 (±3.9) | 24.4 (±3.9) | 0.31 |
| Comorbidities per patient Mean (SD) | 3.2 (±1.2) | 3.2 (±1.4) | 0.86 |
| Comorbidities, n (%) | |||
| Cardiac (a HTN, b CABG, c PCI with stenting) | 56 (87.5) | 88 (88.9) | 0.81 |
| Diabetes | 25 (39) | 46 (46.5) | 0.32 |
| Neurologic (dementia, stroke, d TIA) | 12 (18.8) | 17 (17.2) | 0.82 |
| Oncologic | 10 (15.6) | 10 (10.1) | 0.30 |
| Renal (ESRD, CKD) | 38 (59.4) | 58 (58.6) | 0.82 |
| Respiratory (e COPD, pulmonary, HTN) | 44 (68.8) | 57 (57.6) | 0.12 |
| Admitting Dx, n (%) | |||
| f CHF | 6 (9.3) | 6 (6.0) | 0.43 |
| COPD | 13 (20.3) | 18 (18.2) | 0.74 |
| Myocardial infarction | 10 (15.6) | 7 (7.1) | 0.09 |
| Pneumonia | 10 (15.6) | 21 (21.2) | 0.37 |
| Sepsis | 10 (15.6) | 15 (15.6) | 0.93 |
| Mortality | |||
| In-hospital mortality | 30 (46.9) | 25 (25.3) | <0.05 |
| Code status upon admission to ICU | |||
| No documentation, n (%) | 50 (78.1) | 91 (91.2) | |
| Early conversation or nursing home communication, n (%) | 4 (6.3) | 1 (1.0) | |
| Advanced directives, n (%) | 10 (15.6) | 7 (9.6) | |
| Documented code status discussion within 72 h, n (%) | 64 (100) | 26 (26.3) | |
| Goals of care | |||
| g Non-invasive airway management, n (%) | 26 (40.6) | N/A | |
| Mechanical ventilation, n (%) | 7 (10.9) | N/A | |
| h Vasoactive agents s, n (%) | 8 (12.5) | N/A | |
| Dialysis, n (%) | 4 (6.3) | N/A | |
| Feeds, n (%) | 3 (4.7) | N/A | |
| Comfort care, n (%) | 28 (43.8) | N/A | |
a Hypertension (HTN); b coronary artery bypass graft (CABG); c percutaneous coronary intervention (PCI); d transient ischemic attack (TIA); e chronic obstructive pulmonary disease (COPD); and f congestive heart failure (CHF). g Non-invasive airway management: delivery of oxygen by less aggressive means than endotracheal intubation requiring mechanical ventilation including oxygen via continuous positive airway pressure, biphasic positive airway pressure, and high-flow nasal cannula, etc. h Vasoactive agents: vasopressors (norepinephrine, epinephrine, etc.) and inotropes (dobutamine and milrinone).
Table 2.
Average resource utilization based on code status during hospitalization.
| Resource | Code Status | p-Value (<0.05) | |
|---|---|---|---|
| DNR (n = 64) | Full Code (n = 99) | ||
| Time | |||
| Days in ICU—mean (SD) | 7.7 (±3.6) | 9.9 (±8.3) | <0.05 |
| Days in hospital—mean (SD) | 20.9 (±31.4) | 22.9 (±22.9) | 0.65 |
| a Extrapolated cost related to length of stay | |||
| Average cost during ICU admission | 28,020.3 | 36,026.1 | <0.05 |
| Average cost duration in hospital | 21,568.8 | 23,678.6 | 0.65 |
| Total average cost | 49,589.1 | 59,704.7 | 0.11 |
| b Imaging | |||
| Diagnostic images ordered per patient—mean (SD) | 4.5 (±3.4) | 6.2 (±6.4) | <0.05 |
| Consultations | |||
| Consultations per patient—mean (SD) | 0.9 (±1.1) | 1.1 (±0.9) | 0.48 |
| Consultation—type n (% total consultations) | |||
| Total | 63 | 107 | 0.66 |
| Palliative | 12 (19.0) | 4 (3.7) | <0.05 |
| Cardiology | 9 (14.3) | 26 (24.3) | 0.07 |
| Hematology | 0 (0) | 2 (1.9) | 0.16 |
| Nephrology | 19 (30.2) | 34 (31.2) | 0.61 |
| Internal medicine | 7 (11.1) | 9 (8.4) | 0.66 |
| Surgery | 9 (14.4) | 22 (20.6) | 0.21 |
| Gastroenterology | 1 (1.6) | 4 (3.7) | 0.36 |
| Respiratory | 4 (6.3) | 3 (2.8) | 0.31 |
| Neurology | 2 (3.2) | 4 (3.7) | 0.78 |
| Infectious diseases | 0 (0) | 1 (0.9) | 0.32 |
Table 3.
Admission and discharge functional status and living setting based on code status.
| Functional Status or Living Setting | Code Status | ||
|---|---|---|---|
| Admission | DNR (n = 64) | Full Code (n = 99) | p-Value (<0.05) |
| Living setting | |||
| Home | 47 (73.3) | 85 (85.6) | |
| Assisted | 11 (17.2) | 10 (10.1) | |
| Full care | 6 (9.4) | 4 (4.0) | |
| Hospital | 0 (0) | 0 (0) | |
| a Prior living setting mean (SD) | 1.4 (±0.7) | 1.2 (±0.5) | 0.22 |
| Functional status | |||
| Fully functional/independent living | 10 (15.6) | 23 (23.2) | |
| Partially assisted/family help/community help | 47 (73.4) | 69 (69.7) | |
| Fully assisted/group home | 7 (10.9) | 7 (7.1) | |
| b Admission functional status mean (SD) | 2.0 (±0.5) | 1.8 (±0.5) | 0.56 |
| Discharge | DNR (n = 34) | Full Code (n = 74) | |
| Living setting | |||
| Home | 7 (20.6) | 16 (21.6) | |
| Assisted | 2 (5.9) | 2 (2.7) | |
| Full | 1 (2.9) | 2 (2.7) | |
| Hospital | 24 (70.6) | 54 (72.9) | |
| c Discharge living setting mean (SD) | 1.6 (±0.8) | 1.3 (±0.7) | 0.86 |
| Functional status | |||
| Fully functional/independent living | 1 (2.9) | 5 (6.8) | |
| Partially assisted/family help/community help | 20 (58.8) | 47 (63.5) | |
| Fully assisted/group home | 13 (38.2) | 22 (29.7) | |
| d Discharge functional status mean (SD) | 2.5 (±0.6) | 2.3(±0.6) | 0.30 |
a Prior living setting mean (1 = home, 2 = assisted, and 3 = full). b Admission functional status mean (1 = fully functional/independent living, 2 = partially assisted/family help/community help, and 3 = fully assisted/group home). c Discharge living setting mean (1 = home, 2 = assisted, 3 = full, and 4 = hospital). d Discharge functional status mean (1 = fully functional/independent living, 2 = partially assisted/family help/community help, and 3 = fully assisted/group home).
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MDPI and ACS Style
Kent, J.T.; Ghosh, R. Quantifying the Association Between Code Status Discussions and Outcomes in Critically Ill Older Adults Admitted to the Intensive Care Unit (ICU): A Retrospective Cohort Study. Emerg. Care Med. 2025, 2, 16. https://doi.org/10.3390/ecm2020016
AMA Style
Kent JT, Ghosh R. Quantifying the Association Between Code Status Discussions and Outcomes in Critically Ill Older Adults Admitted to the Intensive Care Unit (ICU): A Retrospective Cohort Study. Emergency Care and Medicine. 2025; 2(2):16. https://doi.org/10.3390/ecm2020016
Chicago/Turabian StyleKent, Jessica T., and Rishi Ghosh. 2025. "Quantifying the Association Between Code Status Discussions and Outcomes in Critically Ill Older Adults Admitted to the Intensive Care Unit (ICU): A Retrospective Cohort Study" Emergency Care and Medicine 2, no. 2: 16. https://doi.org/10.3390/ecm2020016
APA StyleKent, J. T., & Ghosh, R. (2025). Quantifying the Association Between Code Status Discussions and Outcomes in Critically Ill Older Adults Admitted to the Intensive Care Unit (ICU): A Retrospective Cohort Study. Emergency Care and Medicine, 2(2), 16. https://doi.org/10.3390/ecm2020016
