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J Clin Anesth. 2018 Aug;48:81-88. doi: 10.1016/j.jclinane.2018.05.007. Epub 2018 May 18.

Postoperative outcomes in patients with a do-not-resuscitate (DNR) order undergoing elective procedures.

Author information

1
Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States. Electronic address: ebrovman@bwh.harvard.edu.
2
Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States. Electronic address: ewalsh6@bwh.harvard.edu.
3
University of California, San Diego, San Diego, CA, United States. Electronic address: bnburton@ucsd.edu.
4
Harvard Medical School, Boston, MA, United States. Electronic address: ckuo2@partners.org.
5
Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States. Electronic address: charlotta_lindvall@dfci.harvard.edu.
6
University of California, San Diego, San Diego, CA, United States. Electronic address: ragabriel@ucsd.edu.
7
Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States. Electronic address: rurman@bwh.harvard.edu.

Abstract

STUDY OBJECTIVE:

Do-not-resuscitate (DNR) status has been shown to be an independent risk factor for mortality in the post-operative period. Patients with DNR orders often undergo elective surgeries to alleviate symptoms and improve quality of life, but there are limited data on outcomes for informed decision making.

DESIGN:

Retrospective cohort study.

SETTING:

A multi-institutional setting including operating room, postoperative recovery area, inpatient wards, and the intensive care unit.

PATIENTS:

A total of 566 patients with a DNR status and 316,431 patients without a DNR status undergoing elective procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2012.

INTERVENTIONS:

Patients undergoing elective surgical procedures.

MEASUREMENTS:

We analyzed the risk-adjusted 30-day morbidity and mortality outcomes for the matched DNR and non-DNR cohorts undergoing elective surgeries.

MAIN RESULTS:

DNR patients had significantly increased odds of 30-day mortality (OR 2.51 [1.55-4.05], p < 0.001) compared with non-DNR patients. In the DNR versus non-DNR cohort there was no significant difference in the occurrence of a number of 30-day complications, the rate of resuscitative measures undertaken, including cardiac arrest requiring CPR, reintubation, or return to the OR. The most common complications in both DNR and non-DNR patients undergoing elective procedures were transfusion, urinary tract infection, reoperation, and sepsis. Finally, the DNR patients had a significantly increased total length of hospital stay (7.65 ± 9.55 vs. 6.87 ± 9.21 days, p = 0.002).

CONCLUSIONS:

DNR patients, as compared with non-DNR patients, have increased post-operative mortality but not morbidity, which may arise from unmeasured severity of illness or transition to comfort care in accordance with a patient's wishes. The informed consent process for elective surgeries in this patient population should include a discussion of acceptable operative risk.

PMID:
29783184
DOI:
10.1016/j.jclinane.2018.05.007
[Indexed for MEDLINE]

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