High mortality in surgical patients with do-not-resuscitate orders: analysis of 8256 patients

To evaluate outcomes of patients who undergo surgery with a do-not-resuscitate (DNR) order.

Retrospective cohort study.

More than 120 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2008.

There were 4128 adult DNR patients and 4128 age-matched and procedure-matched non-DNR patients.

Outcomes were occurrence of 1 or more postoperative complications, reoperation, death within 30 days of surgery, total time in the operating room, and length of stay. The χ(2) test was used for categorical variables and t and Wilcoxon tests were used for continuous variables. Multivariate logistic regression was done to determine independent risk factors associated with mortality in DNR patients.

Most DNR patients were white (81.5%), female (58.2%), and elderly (mean age, 79 years). Compared with non-DNR patients, DNR patients experienced longer length of stay (36% increase; P < .001) and higher complication (26.4% vs 31%; P < .001) and mortality (8.4% vs 23.1%; P < .001) rates. Nearly 63% of DNR patients underwent nonemergent procedures; they sustained a 16.6% mortality rate. After risk adjustment, DNR status remained an independent predictor of mortality (odds ratio, 2.2; 95% confidence interval, 1.8-2.8). American Society of Anesthesiologists class 3 to 5, age older than 65 years, and preoperative sepsis were among independent risk factors associated with mortality in DNR patients.

Surgical patients with DNR orders have significant comorbidities; many sustain postoperative complications, and nearly 1 in 4 die within 30 days of surgery. Do-not-resuscitate status appears to be an independent risk factor for poor surgical outcome.