{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T08:20:25Z","timestamp":1777882825573,"version":"3.51.4"},"reference-count":35,"publisher":"SAGE Publications","issue":"1","license":[{"start":{"date-parts":[[2025,6,1]],"date-time":"2025-06-01T00:00:00Z","timestamp":1748736000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2025,6,1]],"date-time":"2025-06-01T00:00:00Z","timestamp":1748736000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Palliative Medicine Reports"],"published-print":{"date-parts":[[2025,6,1]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction:<\/jats:title>\n                    <jats:p>Life-support limits (i.e., code status), the first step in the continuum of palliation and end-of-life (EoL) care, stem from decisions made by patients and their providers to align care near the EoL with patients\u2019 wishes. The pandemic created health care strain that may have influenced life-support limitation practices among patients with serious COVID-19. In this study, we examine variations in life-support limitations (do-not-resuscitate, DNR; do-not-intubate, DNI) depending on the hospital and period of hospitalization.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>We included all adults admitted to a hospital in the United States with COVID-19 from January 2020 to December 2021 using the VIRUS registry. Our outcome was any life-support limitation on admission (DNR, DNI, or both) using regression modeling. Main exposures were hospital and period of hospitalization (early vs. late pandemic). Covariates included age, sex, race\/ethnicity, comorbidities, and hospitalization diagnoses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>There were 42,383 patients from 75 hospitals in the US. The median age was 63 (interquartile range: 50\u201375), 46.5% were female, and 37.5% were non-Hispanic White. The life-support limitation rate was 7.9%, and the palliative care consultation rate was 2.3%. The odds of life-support limitation were 1.86 (95% CI: 1.6\u20132.1) depending on the hospital, but the period of hospitalization was not associated with odds of life-support limitation. Older age was associated with the greatest increased odds (4.1 per standard deviation \u223c 17.9 years, 95% CI: 3.9\u20134.4), followed by comorbidities including paralysis (2.4, 95% CI: 1.8\u20133.0) and dementia (2.3, 95% CI: 2.0\u20132.6).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>After adjusting for patient-level factors, we report significant inter-hospital but no temporal variation in life-support limitation upon admission with COVID-19. Future studies should investigate specific practices that led to health care resilience to temporal practice variations in life-support limitation during the pandemic.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/26892820251380523","type":"journal-article","created":{"date-parts":[[2025,9,25]],"date-time":"2025-09-25T15:49:24Z","timestamp":1758815364000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Hospital and Temporal Variations in Limitations of Care Among Hospitalized Patients with COVID-19: A VIRUS Registry Retrospective Cohort Study"],"prefix":"10.1177","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8419-0339","authenticated-orcid":false,"given":"Nathan","family":"Mesfin","sequence":"first","affiliation":[{"name":"Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nitesh","family":"Kumar Jain","sequence":"additional","affiliation":[{"name":"Division of Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anwar","family":"Khedr","sequence":"additional","affiliation":[{"name":"Division of Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hisham","family":"Mushtaq","sequence":"additional","affiliation":[{"name":"Division of Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Abbas B.","family":"Jama","sequence":"additional","affiliation":[{"name":"Division of Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Noura","family":"Attallah","sequence":"additional","affiliation":[{"name":"Division of Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Esraa","family":"Hassan","sequence":"additional","affiliation":[{"name":"Division of Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Benjamin","family":"Langworthy","sequence":"additional","affiliation":[{"name":"Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicholas","family":"Ingraham","sequence":"additional","affiliation":[{"name":"Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Juan Pablo Domecq","family":"Garces","sequence":"additional","affiliation":[{"name":"Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thoyaja","family":"Koritala","sequence":"additional","affiliation":[{"name":"Department of Hospital Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Donna Lee","family":"Armaignac","sequence":"additional","affiliation":[{"name":"Center for Advanced Analytics, Baptist Health South Florida, Coral Gables, Florida, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicholas Eugene","family":"Perkins","sequence":"additional","affiliation":[{"name":"Department of Hospital Medicine, Prisma Health, Greenville Memorial Hospital, Grenville, South Carolina, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katherine","family":"Belden","sequence":"additional","affiliation":[{"name":"Department of Medicine, Division of Infectious Disease, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vishakha","family":"Kumar","sequence":"additional","affiliation":[{"name":"VIRUS Registry, Society of Critical Care Medicine, Mount Prospect, Illinois, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karen","family":"Boman","sequence":"additional","affiliation":[{"name":"VIRUS Registry, Society of Critical Care Medicine, Mount Prospect, Illinois, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Devang K.","family":"Sanghavi","sequence":"additional","affiliation":[{"name":"Department of Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vikas","family":"Bansal","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rahul","family":"Kashyap","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rodrigo","family":"Cartin-Ceba","sequence":"additional","affiliation":[{"name":"Division of Pulmonary Medicine, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Abigail La","family":"Nou","sequence":"additional","affiliation":[{"name":"Department of Critical Care Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Allan J.","family":"Walkey","sequence":"additional","affiliation":[{"name":"Pulmonary Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Evans Center of Implementation and Improvement Sciences, Boston, University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"R. 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