Code status among surgical patients at a rural teaching hospital

Introduction

Advance directives arose from the Patient Self-Determination Act of 1990 with the aim to deliver enhanced patient autonomy, ensuring medical decisions are congruent with patients’ wishes. This was a shift from a paternalistic approach to medical decision making, which has been seen in surgery (1,2). Advance directives have the unique potential to alter the course of patient care, beginning as early as the prehospital setting. Emergency medical services are confronted with this during resuscitation efforts, ensuring there is congruency between care delivered and documented patient wishes during the transition from person to “patient” (3). “Physician Orders for Life-Sustaining Treatment” (POLST), is a document that is part of a national collaboration to allow patients portable, concise communication with the health care team regarding their wishes, from the pre-hospital to hospital setting (4). Within New York state, this takes form as “Medical Orders for Life-Sustaining Treatment” (MOLST), explicitly noting which advance directives have been completed, cardiopulmonary resuscitation preference, code status [Full, do not resuscitate (DNR), DNR/do not intubate (DNI)], and the individual who is making decisions (5).

Upon hospital admission, treatment goals and preferences, including code status, should be known and clarified by the healthcare team. Addressing perioperative code status is especially pertinent for those with code status limitations, including “DNR”, “DNI”, and other modifiers. As many as 15% of patients with DNR/DNI orders will undergo surgical procedures with anesthesia. The American College of Surgeons (6), American Society of Anesthesiologists (ASA) (7) and the Association of periOperative Registered Nurses (8) recommend addressing perioperative resuscitation preferences for DNR/DNI patients undergoing procedures with anesthesia. This allows for clarification and modification of patients’ directives based on their preferences in the perioperative setting, rather than automatic disregard of code status limitations for the sake of the procedure (6). These discussions are critically important in the perioperative setting in coordination with the anesthesia team as undergoing anesthesia has the inherent risk of requiring resuscitative measures and intubation following the procedure.

However, despite a desire to deliver care that is patient-centered, even after deliberate perioperative discussion of advance directives and the information they communicate, there are still challenges with implementation. Providers struggle with both subject content and navigation. Conversation tones can be dismissive, as patients are assessed for their ability to tolerate complications and “sign up” for the postoperative course; they may even feel their own determination to survive is under scrutiny (9). This has been aptly described as the “surgical buy-in” that is required when patient and surgeon enter into the perioperative contract, setting forth a chain of events driven by clinical momentum toward further treatment and intervention (10,11). Navigating documentation is arguably equally daunting and can lead to misinterpretation and disconnect from the reality of the situation that lies before the patient, their family, or designated surrogate (12). When patients are unable to speak for themselves, their surrogate decision makers are tasked with understanding the intricacies of surgery and how they apply to their loved one’s situation. When potentially inundated with information and need for decision, stipulations on prognosis are made based on the patient’s character, outlook, faith, or even “gut feeling”, all which may point the decision maker towards an intervention (13,14).

Although surgeons report eliciting their patient’s preferences for limitations of life-supportive therapy and postoperative care, surgeons are infrequently leading preoperative code status discussions (1,15) and almost half of surgeons do not regularly ask patients if they have an advance directive or confirm the current existence of an advance directive (9). Surgeons find themselves constrained for time and express awareness of their own limitations in communicating about prognosis and goals (14). When dialogue falls short or does not occur, patients may lack prognostic understanding and opt for treatments with high risk-to-benefit ratio (14). Within rural communities, there is a paucity of research devoted to understanding and management of code status, especially for surgical patients. In addition to challenges previously described, further disparities likely exist within this setting, as limited documentation, resources, and health literacy have been identified as proposed barriers to delivering code status programming and action for rural patients across multiple medical specialties (16,17). As nearly one-third of Medicare beneficiaries will undergo an operation in the last three months of life (18) and approximately 38% of patients in the rural setting rely on Medicare for healthcare coverage (19), addressing code status for surgical patients, particularly in the rural setting, is all the more pertinent. To alleviate perioperative confusion about advance directives, standardized and routine conversations should be encouraged (9). Educators in surgery and anesthesiology have advocated for dedicated time to developing this skill in all levels of training (20,21). This study aimed to evaluate code status discussions at a rural teaching hospital, with particular focus on surgical residents’ performance in engaging patients or surrogates and documenting code status directives. We present this article in accordance with the STROBE reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-143/rc).

Methods

We conducted a retrospective analysis of adult (18 years+) emergency department (ED) to inpatient surgical admissions (n=716) from 1/1/2022 to 12/31/2023 at Bassett Medical Center, a rural, tertiary teaching hospital in upstate New York with academic affiliations with Columbia University. Admissions excluded trauma cases and patients who did not undergo a surgical procedure. Patients with multiple admissions were counted on their first encounter. All patients were admitted by the general surgery service, which is a teaching service that additionally cross-covers specialties of vascular surgery, plastic surgery, and otolaryngology (select patients). Electronic health records (EHRs) were queried in the Epic^® system to identify eligible admissions.

Patient characteristics assessed included age, sex, race, insurance status, ASA class, discharge disposition, and procedure. Information related to the procedure included the title of the case requested and which service team requested the procedure. All general surgery service admissions are admitted using a standardized admission order set, which includes code status orders. Code status orders utilized at this hospital have three mandatory components: Medical Orders for Life-Sustaining Treatment (MOLST) were already on file, code status was discussed by the admitting clinician, and a new or revised MOLST was completed. These questions are a “hard stop” in the order set and admission will not occur until these questions and other required components of the order set are addressed. As such, MOLST was selected as a surrogacy for advanced directives, given the mandatory component of code status orders. Within Epic^®, the section labeled “Advance Care Planning (ACP)” may contain any pertinent documentation related to advance directives, ranging from Power of Attorney to MOLST/code status documentation. In addition to the code status order set questions, this section was referenced for all patients. ACP documentation was categorized into five levels: Yes, the patient has an advance directive; No, the patient does not have an advance directive; Unknown, patient unable to respond; Other; and Missing.

Changes in values on the three initial code status order set questions during the hospital stay were tracked. For those who had a revision, changes in code status responses between the first and second instance were categorized as: (I) conversion from all “no” responses to at least one “yes”; or (II) conversion from at least one “yes” to all “no”.

Statistical analysis

Descriptive statistics summarizing sample characteristics, total length of stay, procedure details and code status documentation were produced. Among those with changes to code status order set variables during the admission, the mean elapsed time (in days) between changes was summarized. All data analysis was carried out using SAS version 9.4 (Cary, NC, USA).

This study was conducted in accordance with the principles outlined in the Declaration of Helsinki and its subsequent amendments. It was deemed exempt by The Mary Imogene Bassett Hospital Institutional Review Board (No. 2247540) on October 10, 2024. A request for waiver of informed consent for access to protected health information was granted, as any disclosure of the human subjects’ responses outside the research would not reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects’ financial standing, employability, educational advancement, or reputation. This research involves only information collection and analysis involving the investigator’s use of identifiable health information when that use is regulated under 45 CFR parts 160 and 164, subparts A and E, for the purposes of “health care operations” or “research” as those terms are defined at 45 CFR 164.501 or for “public health activities and purposes” as described under 45 CFR 164.512(b).

Results

Patient demographics and characteristics

Among the n=716 included admissions, the mean patient age was 62.17 (standard deviation =16.76) years, 368 (51.40%) were male, and 688 (96.09%) were White/Caucasian (Table 1). Fewer than 1% were uninsured (Table 1). Mean length of stay was 7.44 (standard deviation =7.53) days and discharge disposition was most often to home/self care (60.61%) or to a home health provider (22.35%). Fewer than 2% of patients had expired (Table 1).

Perioperative characteristics

Approximately 63% of cases were requested and performed by the general surgery service. Non-surgical services requesting cases included cardiology, gastroenterology (8.80%), and pulmonology (Table 2). Most patients were either ASA Class 2 (22.21%) or Class 3 (60.32%) (Table 2). The most frequent procedures performed included laparotomy (11.31%), laparoscopic cholecystectomy (11.17%), laparoscopic appendectomy (6.56%), exploratory/diagnostic laparoscopy (4.47%) and esophagogastroduodenoscopy (3.77%) (Table 3).

Admission orders and medical orders for life sustaining treatment

In 94% of admissions, “NO” was answered to all three MOLST questions (i.e., there was no prior MOLST or DNR on file, no documented code status discussion, and no MOLST completion or revision). Only 3% arrived with a MOLST, and fewer than 1% had MOLST revision at admission. Fewer than 3% had a code status limitation of either “DNR” or “DNR/DNI” (Table 4). Those with code status limitations at admission were older and had a longer total hospital length of stay (mean age =77.82 years, mean LOS =9.84 days) than those without code status limitations (mean age =61.79 years, mean LOS =7.38 days). A greater percentage of patients with code status limitations expired during the admission (17.65%) compared to those without code status limitations (1.57%). A greater percentage of patients with code status limitations also had an ASA Class over 3 (41.18% ASA 4; 0% ASA 5) compared to those without code status limitations (15.71% ASA 4, 0.15% ASA 5). About 24.44% of patients had some form of ACP documentation. Of the patients who were documented to have all “NO” to initial code status order set questions, i.e. does not have a prior MOLST on file/with them, did not have a discussion with a provider regarding code status, and did not have a MOLST completed/revised, 23.74% were indicated as having ACP documents in their EHR (Table 4). About 91.43% of patients documented as having ACP documents on file also had an answer of “NO” to all three MOLST questions in their admission order set (n=160 answered all “NO”/175 with ACP documents on file). Some patients had their initial code status questions revisited during their hospital stay, some as many as 5 times (Table 5). Time to conversation from all “NO” responses to at least one “YES” was on average 7.07 (standard deviation =7.69) days (Table 5).

Discussion

Fewer than 3% of patients admitted to a rural surgery teaching service had a code status limitation identified upon admission. Those with code status limitations were often older and sicker, as defined by ASA class. These patients had longer hospital stays and were more likely to have expired during their admission. 91.43% of patients documented as having ACP documents on file also had an answer of “NO” to all three MOLST questions in their admission order set. This raises an important question of whether code status is being discussed with surgical patients who are admitted to the hospital and if those discussions are being documented accurately in the EHR. A theory raised by the authors, is that the admitting provider, often a resident, may be entering in orders that reflect no code status limitation (i.e., all “NO’s”) because there was insufficient time to discuss code status with the patient or their surrogate, but then did not return to the discussion. Discrepancy may also arise with how the provider interacts with patients’ medical records. The transition from paper to electronic medical records has allowed provider access to a patient’s chart anywhere in the hospital. Within the EHR utilized in this study, there is an “advance care planning (ACP)” notification near patient identifiers that when expanded, can display code status history and is home to many types of documents, including power of attorney, living will, and MOLST forms. This notification can be useful to providers by signaling whether there may already be documentation on file pertaining to code status. However, further complicating matters, a document can be marked as on-file by the phrase “Patient has ACP documents”, but the scan of the physical copy may not be linked, functionally rendering the document absent and unable to be acted upon, or even irrelevant documentation (ex. Consent for a bedside procedure or EKG) may be mistakenly linked here. Chart review is needed within this data set to determine if these patients who had ACP documentation truly had no MOLST on file. Although the EHR has provided many advancements in the integrity of health information and the delivery of care, this study highlights the human component that is necessary for interfacing between technology and caring for patients as well as possible limitations.

To our knowledge there is no study to date that examines the quality and consistency of code status documentation in surgical patients, specifically within a rural hospital setting. This work is all the more important as over the years, there has been a shift in the United States, where people are leaving rural areas for more urban and suburban areas. Those that remain in rural settings are often older, with greater co-morbidities, and with reduced incomes (22). These patients desire care close to home and often are willing to accept greater operative risk in the effort to do so (23). Our study population is primarily one that is aging, with mean age of 62 years and nearly 3/4 utilizing Medicare or Medicaid for healthcare coverage. Rural hospitals and systems face unique challenges, often serving large catchments. Systems must be conscious of resource availability and the associated limitations. This has presented as scarcity in specialty services, such as palliative care, as well as time constraints faced by providers who are responsible for cross coverage of services (24,25). General surgeons are tasked with performing a greater range of endoscopy services when gastroenterology services are reduced (24). Yet as shown here with most frequently performed surgeries including cholecystectomy, colectomy, and exploratory laparotomy, rural surgeon productivity reflects national trends with similarly performed procedures (24,26). This reiterates the importance of addressing patient’s wishes before proceeding with surgery, which inherently comes with potential threats to patients’ quality of life.

Given these demands, the American College of Surgeons has developed the Advisory Council for Rural Surgery as an active effort to train, support, and secure the future of rural general surgery. A component of this effort is the establishment of rural general surgery tracks to train broad-based, competent, and safe general surgeons that will ultimately go on to serve rural communities (27). Additionally education should include how to conduct code status discussions and difficult conversions with surgical patients, as well as bridging gaps in surgical care that are currently faced by rural areas, especially as more and more trainees seek to specialize (28).

Limitations of this study include the retrospective design, use of MOLST as a surrogate for communicated code status across all patient populations, and issues in documentation. MOLSTs were intended for patients facing critical illness or frailty, regardless of age. From this analysis, it can be challenging to interpret which patients from this data set would be of greatest benefit to completion of a MOLST, if following this definition. Additionally, there is possible variation in interpretation of MOLST documentation and order entering. We have identified examples of discrepancies that exist in the EHR. To explore this, further chart review would be necessary to investigate whether patients truly had a MOLST on file, as possibly suggested by the ACP notification, and understand discrepancies between documentation by an admitting provider and the actual information within a patient’s chart. Further, such a review would assist in determining whether findings accurately reflect patient-clinician interactions and documentation in the EHR. To better understand how to assist and educate providers, future work will include a survey of the general surgery residency, assessing residents’ attitudes, practices, facilitators, and barriers regarding code status discussions, as they are often the first clinicians to interact with patients upon admission. From this survey, we aim to develop interventions that support and train future surgeons to be active participants in code status discussions and their engagement with patients and their family members.

Conclusions

Addressing code status with surgical patients is a critical component of providing complete surgical care during their hospital stay, yet our results add to evidence of inconsistency in doing so. Potential barriers include provider time constraints, accurate documentation and navigation of information within the electronic health record, and system-specific resource limitations. Awareness of this deficit and general surgery resident education efforts are proposed strategies for ensuring appropriate, informed, and patient-centered code status management for every surgical patient.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-143/rc

Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-143/dss

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-143/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-143/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. It was deemed exempt by The Mary Imogene Bassett Hospital Institutional Review Board (No. 2247540) on October 10, 2024. A request for waiver of informed consent for access to protected health information was granted.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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