Code status documentation during the COVID-19 pandemic 111 5 pandemic (40% vs 24% of all documented code status). Both are relatively high compared with earlier research, which show treatment limitation frequencies ranging from 9% to 23%.25–29 Since hospital type is known to influence code status documentation, the already high frequency before the COVID-19 pandemic seems appropriate given our academic tertiary centre patient population.28 29 The increase of treatment limitations during the COVID-19 pandemic might even be underestimated, as patient characteristics known to increase do-not-resuscitate documentation (e.g., malignancy and CCI) were lower during the COVID-19 pandemic, possibly as a result of the transfers from non-tertiary hospitals.30 The distribution of limitations also shows an increased limitation-directed tendency: ‘no intubation’ and ‘no ICU admission’ were substantially more prevalent in COVID-19 patients than before the COVID-19 pandemic (81% vs 51% resp. 69% vs 40%). To our knowledge, only one other study thus far compared code status documentation before and during the COVID-19 pandemic, a single centre study by Coleman et al in the UK. In contrast to our study, they reported a substantially increased documentation of code status during the COVID-19 pandemic (from 20% before COVID-19% to 50% during COVID-19).7 However, in their hospital, there was a change of policy at the start of the pandemic to expand code status documentation to all inpatients, which was already standardly instructed in our medical centre before the pandemic.7 This is also reflected in our remarkably higher code status documentation even before the pandemic of 73%, as compared with 20% in their study population before the pandemic, presumably leaving less space for improvement. Earlier studies on non-mandatory code status documentation reported a wide range of documentations from 3% to 61%(1, 7–9). Furthermore, Coleman et al report more patients with full active treatment during the COVID-19 pandemic,7 while we see more treatment limitations. However, the earlier mentioned increase in code status documentation in their study might have influenced the proportion of full code versus treatment limitations, thus no definite conclusion was drawn by Coleman et al about the precise influence of the pandemic on treatment limitations.7 To explore whether the increase in ‘no intubation’ and ‘no ICU admission’ was due to the nature of the COVID-19 disease, or other factors as increased awareness during the pandemic, we additionally compared the COVID-19 patients to only the patients with respiratory infections. Since similar differences were found when
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