Perioperative Continuation of Code-status Limitations and Early Postoperative Mortality: A Retrospective Cohort Study.

Abstract

The objective of this study was to determine whether perioperative continuation of code status limitations is associated with early postoperative mortality and to characterize postoperative code-status trajectories preceding early deaths. Decisions about perioperative management of do-not-resuscitate (DNR) orders are common, yet their relationship to early postoperative outcomes remains poorly understood. This was a retrospective cohort study conducted from March 2024 to June 2025 across 5 hospitals within a single academic health system. We included adults aged 18 years or older who presented for a procedure under anesthesia with a code status other than full code. The exposure was perioperative code status (reversal to full code vs. not full code). The primary outcome was all-cause mortality within 3 days of the procedure. The secondary outcome was use of invasive hemodynamic monitoring. Associations were estimated using multivariable logistic regression. Among 2833 eligible patients, none were excluded. The median age was 79 years (IQR, 70-86), and 59% were women. Of 2833 patients, 2323 (82%) reversed to full code perioperatively, and 510 (18%) remained not full code. Forty-four patients (1.6%) died within 3 days. Three-day mortality occurred in 15 of 510 patients (2.9%) who remained not full code and in 29 of 2,323 patients (1.2%) who reversed to full code. After adjustment for age, sex, ASA physical status, operative stress score, and race, not full code status was associated with higher odds of 3-day mortality (adjusted odds ratio, 2.18; 95% CI, 1.14-4.16), corresponding to an adjusted absolute risk difference of 1.43% (95% CI, 0.06%-2.95%). Among patients who died within 3 days and remained hospitalized, 34 of 42 (81%) died after transition to comfort-focused care. Invasive hemodynamic monitoring was more common among patients who remained not full code (adjusted absolute risk difference, 3.74%; 95% CI, 0.91%-6.93%). Among adults presenting for a procedure with code-status limitations, continuation of a nonfull code status was associated with higher early postoperative mortality. This pattern reflects downstream clinical trajectories and treatment decisions rather than missed opportunities for perioperative rescue.