Failure-to-Pursue Rescue
- 1 September 2012
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Annals of Surgery
- Vol. 256 (3), 453-461
- https://doi.org/10.1097/sla.0b013e31826578fb
Abstract
To describe the outcomes of elderly patients with do-not-resuscitate (DNR) status who undergo emergency general surgery and to improve understanding of the relationship between preoperative DNR status and postoperative mortality. Preoperative DNR status has previously been shown to predict increased postoperative mortality, although the reasons for this association are not well understood. Patients 65 years or older undergoing emergency operation for 1 of 10 common general surgical diagnoses were extracted from the 2005-2010 National Surgical Quality Improvement database. Propensity score techniques were used to match patients with and without preoperative DNR orders on indication for procedure, patient demographics, comorbid disease burden, acute physical status at the time of operation, and procedure complexity. The postoperative outcomes of this matched cohort were then compared. A total of 25,558 patients were included for analysis (DNR, n =1061; non-DNR, n =24,497). DNR patients seemed to be more acutely and chronically ill than non-DNR patients in the overall study sample but did not seem to be treated less aggressively before or during their operations. Propensity-matching techniques resulted in the creation of a cohort of DNR and non-DNR patients who were well matched for all preoperative and intraoperative variables. DNR patients from the matched cohort had a significantly higher postoperative mortality rate than non-DNR patients (36.9% vs 22.3%, P < 0.0001) despite having a similar rate of major postoperative complications (42.1% vs 40.2%, P = 0.38). DNR patients in the propensity-matched cohort were much less likely to undergo reoperation (8.3% vs 12.0%, P = 0.006) than non-DNR patients and were significantly more likely to die in the setting of a major postoperative complication (56.7% vs 41.4%, P = 0.001). Emergency general surgery in elderly patients with preoperative DNR orders is associated with significant rates of postoperative morbidity and mortality. One reason for the excess mortality in these patients, relative to otherwise similar patients who do not have preoperative DNR orders, may be their greater reluctance to pursue aggressive management of major complications in the postoperative period.Keywords
This publication has 15 references indexed in Scilit:
- Link between decisions regarding resuscitation and preferences for quality over length of life with heart failureEuropean Journal of Heart Failure, 2012
- High Mortality in Surgical Patients With Do-Not-Resuscitate OrdersArchives of Surgery, 2011
- Pre-existing do-not-resuscitate orders are not associated with increased postoperative morbidity at 30 days in surgical patients*Critical Care Medicine, 2011
- Advance Directives and Outcomes of Surrogate Decision Making before DeathThe New England Journal of Medicine, 2010
- Variation in Hospital Mortality Associated with Inpatient SurgeryThe New England Journal of Medicine, 2009
- Variation in the Rates of Do Not Resuscitate Orders After Major Trauma and the Impact of Intensive Care Unit EnvironmentThe Journal of Trauma and Acute Care Surgery, 2008
- Surgical Risk Factors, Morbidity, and Mortality in Elderly PatientsJournal of the American College of Surgeons, 2006
- Understanding of Prognosis Among Parents of Children Who Died of CancerPublished by American Medical Association (AMA) ,2000
- Relationship Between Cancer Patients' Predictions of Prognosis and Their Treatment PreferencesJama-Journal Of The American Medical Association, 1998
- Life-Sustaining TreatmentArchives of Internal Medicine, 1988