Surgical Outcomes May Be Affected by DNR Orders
A new study published online today by the Archives of Surgery, one of the JAMA/Archives journals, reports surgical patients with do-not-resuscitate (DNR) orders appear to be at higher risk for poor surgical outcomes. The study will appear in the August print issue of the journal.
Do-not-resuscitation (DNR) orders do not preclude the use of surgery in patients. DNR orders do preclude the use of cardiopulmonary resuscitation in a patient who is clinically unresponsive and has no pulse.
DNR orders are generally associated with advanced disease. Often these orders are surrogate markers of impending death. Approximately 70% of patients in the United States die with a DNR order, which is often written within the 3 days immediately preceding death.
Often the surgery patients with a DNR order consent to are surgical procedures aimed at improving the quality of life or decreasing pain or treating an isolated problem such as a fractured hip.
Hadiza Kazaure, B.Sc., and colleagues from Yale University School of Medicine, New Haven, Conn., analyzed data from the more than 120 hospitals participating in the American College of Surgeons Quality Improvement Program from 2005 to 2008. There were 4,128 adult patients with DNR orders and 4,128 age-matched and procedure-matched patients without DNR orders. The main outcome measured were occurrence of one or more post-operative complication, re-operation, death within 30 days of surgery, total time in the operating room and length of stay.
The majority of the DNR patients were white (81.5%), female (58.2%), and elderly (mean age, 79 years).
The DNR patients experienced longer length of stay (36% increase; P
More than twice as many DNR patients died within 30 days of surgery (23.1% vs 8.4%). The DNR patients were more likely to die regardless of the urgency of the surgical procedure (35.5% vs. 17.8%).
The authors found that patients with DNR orders were more likely to die after every procedure analyzed; after adjustment for multiple risk factors, a DNR order was associated with an increased odds of death.
"The DNR patients may have surgery to gain 'additional time'; nevertheless, our study demonstrates that almost a quarter of DNR patients die within 30 days of surgery. Informed consent and elicitation of the goals of surgery, especially as they relate to overall goals of care, are essential for guiding surgical decisions involving DNR patients and their families. Issues pertaining to DNR status are complex, and they should be anticipated long before the 30-day period leading to an operation. Additional research is needed to evaluate the decision making of DNR patients with respect to undergoing surgery, particularly in the non-emergent setting, and the impact of a pre-operative DNR order on post-operative surgical care and to determine the long-term outcomes of DNR patients by procedure," the authors conclude.
The authors note that the use of DNR orders has been increasing and now up to 15% of patients with a DNR order have surgery.
High Mortality in Surgical Patients With Do-Not-Resuscitate Orders: Analysis of 8256 Patients; Hadiza Kazaure; Sanziana Roman; Julie A. Sosa; Arch Surg. 2011;0(2011); doi:10.1001/archsurg.2011.69