Code status documentation during the COVID-19 pandemic 105 5 Strengths and limitations of this study The effect of the pandemic on code status discussion and documentation is largely unknown. This is the first study to compare code status documentation of patients admitted with COVID-19 and patients before the COVID-19 pandemic in the Netherlands. Results can be useful for improving code status documentation and discussion. This study had few missing values, improving the accuracy and reliability of our results. Due to differences between the cohorts, statistical comparison was not appropriate and results are therefore descriptive. 1. Introduction Code status discussions are crucial to ensure future healthcare decisions are aligned to a patient’s wishes. In a code status, it can be documented whether there are limitations to specific life-sustaining treatments or not. Code status discussion has shown to reduce length of stay in the intensive care unit (ICU), ICU readmission rates and costs of healthcare, without impacting patient satisfaction.1–3 Discussing code status in time is essential to prevent unnecessary or undesirable care in acute settings.1 3 Therefore, it is recommended in the Netherlands to discuss code status with every patient on admission. This can be documented in the electronic health record (EHR). In March 2020, the COVID-19 pandemic reached in the Netherlands, putting tremendous pressure on patient care and hospital capacity, especially on the ICU.4–6 We received signals from the professional field that code status documentation and discussion increased as a result of the awareness to the possible shortage of care, inside and outside the ICU,7–9 and attention that was raised to the considerable risks and disadvantages of long-term intubation and ICU admission after infection with COVID-19.7–11 This increased awareness was not only in the medical world, also in the media there was a lot of attention for disadvantages of intubation and ICU admission, which might have stimulated patients to broach the topic when the physician did not. Conversely, a well-known argument not to discuss code status is lack of time.12–15 Hence, code status documentation could be negatively affected by the pandemic as workload for clinicians rapidly increased along with the
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