More DNR Patients Die After Emergency Surgery

Abstract

San Francisco – Elderly patients with preexisting Do Not Resuscitate directives appear to be less likely to pursue rescue (aggressive treatment) of complications following emergency surgery than similar patients without such orders, according to an analysis of data from the National Surgical Quality Improvement Program. When patients with preoperative DNRs were propensity-matched with non-DNR patients, major complication rates were similar – 42% for the DNR group and 41% for the non-DNR group. However, 37% of DNR patients died, compared with 22% of non-DNR patients, Dr. John E. Scarborough reported at the annual meeting of the American Surgical Association. The investigators adjusted for baseline differences in level of illness to create a propensity-matched cohort of 1,053 patients in each group. “While we called this outcome failureto-rescue, we believe that term to be misleading. The term implies that rescue from complications is attempted but is unsuccessful. ... We had no reason to believe that the DNR patients in this well-matched cohort were any less capable of being rescued than nonDNR patients,” Dr. Scarborough said. “Instead, we believe that the DNR patients in the matched cohort were less likely than non-DNR patients to pursue rescue from complications.” This conclusion is supported by the finding that DNR patients were significantly less likely to undergo reoperation within 30 days of the index procedure (odds ratio, 0.67). The authors used participant files from the National Surgical Quality Improvement Program (NSQIP) for 2005–2010, involving medical records for 25,558 patients. These patients were at least 65 years old and underwent an emergency operation for one of 10 common surgical diagnoses. The primary predictor variable was preoperative DNR status, which was defined as “an order signed or cosigned by an attending physician in the 30 days prior to surgery ... regardless of whether the DNR order was subsequently rescinded immediately before the index operation.” Other predictor variables included patient demographics, chronic comorbid disease burden, acute physical condition at presentation, and complexity of the emergency operation. Outcome variables included the 30-day postoperative mortality rate and the 30-day major complication rate – organ/space surgical site infection, wound dehiscence, deep vein thrombosis, pulmonary embolism, pneumonia, reintubation, ventilator use longer than 48 hours, cardiac arrest, myocardial infarction, sepsis, shock, coma longer than 24 hours, prosthetic/graft failure, and bleeding. The failure-to-rescue rate was defined as the mortality rate among patients who had one or more major complications.