Electing Full Code in Hospice: Patient Characteristics and Live Discharge Rates

Background: It is unknown how many hospice enrollees elect to be full code and if this is associated with higher hospice live discharge rates. Objective: To measure the rates of hospice enrollees electing full code, the characteristics predicting full code status, and the association of full code status with various hospice live discharge patterns. Design: Retrospective cohort study of electronic medical record data. Setting/Subjects: A total of 25,636 decedents enrolled in two Michigan hospices between 2009 and 2014. Measurements: Code status was defined as full code versus do-not-resuscitate (DNR) orders. Covariates include demographics, location (home, hospice facility, nursing home, and hospital), primary diagnosis, and length of stay. Hospice live discharge was defined as short (0-14 days), medium (15-179 days), and long (>179 days). Results: A total of 12.9% of hospice enrollees elected full code status. This was significantly (p < 0.05) predicted by male sex, younger age, nonwhite race, home setting of care, and cancer diagnosis. Those with full code status had 1.76 times the adjusted odds of hospice live discharge compared with those with DNR orders (95% confidence interval [CI] 1.44-2.16) and 2.47 times the odds of short live discharge (95% CI 1.69-3.62) with no significant difference in long live discharge. The association of full code orders with hospice live discharge was stronger for nonwhite enrollees, with a live discharge rate of 23.8% versus 11.6% for African Americans with full code versus DNR orders. Conclusions: Those electing full code status on admission to hospice are at high risk of live hospice discharge after short enrollments, particularly nonwhite enrollees.