Patient Perspectives on Preoperative Code Status Discussions: A Qualitative Analysis.

Abstract

Professional guidelines from the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS) emphasize the importance of preoperative communication regarding code status, particularly for patients with limitations on resuscitation. However, little is known about how surgical patients with DNR/DNI or MOLST orders perceive these conversations. To understand patient perspectives to improving perioperative communication and aligning care with patient values. This study included 12 adult surgical patients aged 65 and older with documented treatment-limiting directives in the electronic medical record, recruited from a tertiary academic medical center between September 2024 and March 2025. We conducted semi-structured interviews with eligible patients before their scheduled operations. Interview content focused on patient understanding of code status documentation, experiences with prior discussions, expectations for perioperative management, and preferences for future conversations. Transcripts were analyzed using a hybrid deductive-inductive qualitative content approach. Seventy-five percent of participants were aware of their documented resuscitation preferences, but fewer than half recalled having a preoperative discussion. Three-quarters experienced discordance between their EMR documentation and personal understanding of code status. Thematic analysis revealed four major findings: (1) conflict and stress related to surgical "buy-in," (2) disappointment with system-level factors, (3) limited patient understanding, and (4) trust arising from shared decision-making. Participants described time pressure, fragmented care, and unclear documentation as barriers to meaningful conversations. This study offers novel insight into how older surgical patients with treatment-limiting directives experience perioperative code status discussions. Findings highlight gaps in communication, systemic barriers, and patient-identified needs for trust, continuity, and time to reflect. These insights may inform efforts to improve serious illness communication and support patient-centered perioperative care.