Perioperative Continuation of Code-status Limitations and Early Postoperative Mortality

OBJECTIVE: 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. SUMMARY BACKGROUND DATA: Decisions about perioperative management of do-not-resuscitate (DNR) orders are common, yet their relationship to early postoperative outcomes remains poorly understood. METHODS: 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. RESULTS: 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%). CONCLUSIONS: 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.