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OBJECTIVES:
Patients with recent Do Not Resuscitate (DNR) orders may still be offered surgery to prolong life or improve its quality. The widely accepted approach of “required reconsideration” mandates that patients and surgeons discuss perioperative risks and expected outcomes in the context patient values and preferences. However, surgical outcomes in this patient population have not been well-defined. The objectives of this study are to assess outcomes in DNR patients undergoing major vascular procedures and develop an evidence basis for informed, shared decision making.
METHODS:
Patients undergoing major vascular procedures were identified in the 2007-2010 National Surgical Quality Improvement Project (NSQIP). DNR Patients were defined as those with an active DNR order within 30 days prior to surgery. Demographics, co-morbidities, procedural details, and complications were compared to those without DNR orders. To isolate the impact of DNR status, multivariate regression and 1:1 propensity score matching were used to compare outcomes between DNR patients and a non-DNR cohort of comparably high risk patients.
RESULTS:
Of 108,714 patients undergoing major vascular surgery, 1565 (1.4%) had active DNR orders 30 days preceding surgery. DNR patients were more likely to be functionally dependent (69% vs. 15%; P<.001), >80 years old (53% vs. 20%; P<.001), and suffer from a variety of cardiac, pulmonary, and systemic comorbidities. The most common procedures in DNR patients were major amputation (38.4%), lower extremity bypass (20%), and peripheral thromboembolectomy (11.7%). Unadjusted 30-day mortality was significantly higher among DNR patients (21% vs. 3.4%; P<.001). After 1:1 propensity score matching, 2 cohorts of 1538 patients differed only with respect to DNR status. Mortality remained significantly higher among DNR patients (21% vs. 13%; P<.001). There was a trend towards reduced CPR in DNR patients (1.7% vs. 2.6%; P = 0.07).
CONCLUSION:
Patients with recent DNR status are at high risk for major complications and mortality after vascular surgery. Compared to a matched cohort of “high risk” non-DNR patients, those with recent DNR orders suffered equivalent rates of post-operative morbidity, but markedly increased mortality. This suggests that DNR status, independent of co-morbidities and perioperative complications, increases the risk of “failure to rescue” and mortality. This has implications not only for risk adjustment, but also provides an evidence basis for shared decision making in challenging circumstances.