Failure-to-pursue rescue: explaining excess mortality in elderly emergency general surgical patients with preexisting "do-not-resuscitate" orders.

Published

Journal Article

OBJECTIVE: 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. BACKGROUND: Preoperative DNR status has previously been shown to predict increased postoperative mortality, although the reasons for this association are not well understood. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Full Text

Duke Authors

Cited Authors

  • Scarborough, JE; Pappas, TN; Bennett, KM; Lagoo-Deenadayalan, S

Published Date

  • September 2012

Published In

Volume / Issue

  • 256 / 3

Start / End Page

  • 453 - 461

PubMed ID

  • 22868360

Pubmed Central ID

  • 22868360

Electronic International Standard Serial Number (EISSN)

  • 1528-1140

Digital Object Identifier (DOI)

  • 10.1097/SLA.0b013e31826578fb

Language

  • eng

Conference Location

  • United States