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

Publication ,  Journal Article
Scarborough, JE; Pappas, TN; Bennett, KM; Lagoo-Deenadayalan, S
Published in: Ann Surg
September 2012

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.

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Published In

Ann Surg

DOI

EISSN

1528-1140

Publication Date

September 2012

Volume

256

Issue

3

Start / End Page

453 / 461

Location

United States

Related Subject Headings

  • United States
  • Surgical Procedures, Operative
  • Surgery
  • Resuscitation Orders
  • Propensity Score
  • Postoperative Complications
  • Multivariate Analysis
  • Male
  • Logistic Models
  • Humans
 

Citation

APA
Chicago
ICMJE
MLA
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Scarborough, J. E., Pappas, T. N., Bennett, K. M., & Lagoo-Deenadayalan, S. (2012). Failure-to-pursue rescue: explaining excess mortality in elderly emergency general surgical patients with preexisting "do-not-resuscitate" orders. Ann Surg, 256(3), 453–461. https://doi.org/10.1097/SLA.0b013e31826578fb
Scarborough, John E., Theodore N. Pappas, Kyla M. Bennett, and Sandhya Lagoo-Deenadayalan. “Failure-to-pursue rescue: explaining excess mortality in elderly emergency general surgical patients with preexisting "do-not-resuscitate" orders.Ann Surg 256, no. 3 (September 2012): 453–61. https://doi.org/10.1097/SLA.0b013e31826578fb.
Scarborough, John E., et al. “Failure-to-pursue rescue: explaining excess mortality in elderly emergency general surgical patients with preexisting "do-not-resuscitate" orders.Ann Surg, vol. 256, no. 3, Sept. 2012, pp. 453–61. Pubmed, doi:10.1097/SLA.0b013e31826578fb.
Scarborough JE, Pappas TN, Bennett KM, Lagoo-Deenadayalan S. Failure-to-pursue rescue: explaining excess mortality in elderly emergency general surgical patients with preexisting "do-not-resuscitate" orders. Ann Surg. 2012 Sep;256(3):453–461.

Published In

Ann Surg

DOI

EISSN

1528-1140

Publication Date

September 2012

Volume

256

Issue

3

Start / End Page

453 / 461

Location

United States

Related Subject Headings

  • United States
  • Surgical Procedures, Operative
  • Surgery
  • Resuscitation Orders
  • Propensity Score
  • Postoperative Complications
  • Multivariate Analysis
  • Male
  • Logistic Models
  • Humans