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Crit Care Med. 2011 May;39(5):1036-41. doi: 10.1097/CCM.0b013e31820eb4fc.

Pre-existing do-not-resuscitate orders are not associated with increased postoperative morbidity at 30 days in surgical patients.

Author information

1
Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA. saagerl@ccf.org

Abstract

OBJECTIVE:

To assess the relationship between pre-existing do-not-resuscitate orders and the incidence of postoperative 30-day minor morbidity in surgical patients.

DESIGN:

Retrospective analysis of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database in patients undergoing general surgical procedures between 2005 and 2008.

SETTING:

All U.S. hospitals that participated in the American College of Surgeons National Surgical Quality Improvement Program, which is the nationally validated, risk-adjusted, outcomes-based program that uses a prospective, peer-controlled, validated database to quantify 30-day risk-adjusted surgical outcomes, allowing valid comparison of outcomes among all hospitals in the program.

INTERVENTIONS:

American College of Surgeons National Surgical Quality Improvement Program data included preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both the inpatient and outpatient setting. The data were collected, validated, and submitted by a trained Surgical Clinical Reviewer at each site. Association between do-not-resuscitate status and minor and major morbidities was assessed using proportional hazards models adjusting for death as a competing risk.

MEASUREMENTS AND MAIN RESULTS:

Of 635,265 patients in the database, 576,745 patients were analyzed. Propensity-matched analysis successfully matched 2,199 (of 2,687 [81.8%]) patients having pre-existing do-not-resuscitate orders (DNR group) with 6,002 non-do-not-resuscitate control subjects (nonDNR group). At any time point within 30 days of surgery, DNR patients were 16% (95% confidence interval, 3-28%; p = .02) less likely to have a minor complication as compared with nonDNR patients after accounting for the competing risk of death. DNR patients were more likely to experience 30-day mortality compared with nonDNR patients (hazard ratio, 2.3; 95% confidence interval, 1.9-2.7; p < .001). However, there was no association between pre-existing do-not-resuscitate orders and occurrence of any major complication (p = .65) treating death as a competing risk event. When associations between do-not-resuscitate orders and individual minor complications were analyzed, a pre-existing do-not-resuscitate order remained independently associated only with decreased odds of superficial surgical site infection (p = .001).

CONCLUSIONS:

Undergoing surgery with a pre-existing do-not-resuscitate order did not increase the risk of having a postoperative minor or major morbidity at any time within the 30-day postoperative period. Results of health care in U.S. hospitals do not differ based on presence of do-not-resuscitate orders.

PMID:
21336133
DOI:
10.1097/CCM.0b013e31820eb4fc
[Indexed for MEDLINE]
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