Code status among surgical patients at a rural teaching hospital

BACKGROUND: Code status is infrequently addressed in surgical disciplines unless there is a specific triggering event. Consistency and quality of code status discussions at a rural teaching hospital were evaluated, focusing on surgical residents' performance.

METHODS: Study was conducted at Bassett Medical Center in Cooperstown, New York, a rural teaching, tertiary hospital. Bassett Healthcare Network has affiliations with Columbia University. A retrospective analysis of emergency department (ED) to inpatient surgical admissions from 1/1/2022 to 12/31/2023 was conducted of surgical patients (n=716) 18 years or older, excluding trauma, multiple admissions, and patients without a surgical procedure. Patient age, sex, race, insurance status, American Society of Anesthesiologists (ASA) class, discharge disposition, procedure, and service team requesting the procedure were collected. Code status orders were reviewed to assess whether Medical Orders for Life-Sustaining Treatment (MOLST) were on file, code status was discussed by the admitting clinician, and a new or revised MOLST was completed.

RESULTS: About 94% of patients were documented as having no MOLST form, nor explicit discussion of code status resulting in completion of a MOLST form. 24.44% of patients had advance care planning documents in their electronic health record. 91.43% of these patients also had "NO" to all three MOLST questions in their admission orders. Majority of patients were ASA class 3 (60%) and most common surgeries were laparotomy (11.31%), laparoscopic cholecystectomy (11.17%), laparoscopic appendectomy (6.56%), and esophagogastroduodenoscopy (3.77%).

CONCLUSIONS: Discussing code status with surgical patients is critical to providing complete surgical care, yet our results add to evidence of inconsistency in doing so. Rural areas face additional challenges, such as resource scarcity and older, comorbid populations. To bridge these gaps in surgical care, there is necessity for additional programming, such as rural surgical training programs, to ensure appropriate, informed, and patient-centered code status management for every surgical patient, regardless of geography.