Do-Not-Resuscitate status as an independent risk factor for patients undergoing surgery for hip fracture

To determine morbidity and mortality in hip fracture patients and also to assess for any independent associations between Do-Not-Resuscitate (DNR) status and increased post-operative morbidity and mortality in patients undergoing surgical repair of hip fractures.

We conducted a propensity score matched retrospective analysis using de-identified data from the American College of Surgeons' National Surgical Quality Improvement Project (ACS NSQIP) for all patients undergoing hip fracture surgery over a 7 year period in hospitals across the United States enrolled in the ACS NSQIP with and without DNR status. We measured patient demographics including DNR status, co-morbidities, frailty and functional baseline, surgical and anaesthetic procedure data, post-operative morbidity/complications, length of stay, discharge destination and mortality.

Of 9218 patients meeting the inclusion criteria, 13.6% had a DNR status, 86.4% did not. Mortality was higher in the DNR compared to the non-DNR group, at 15.3% vs 8.1% and propensity score matched multivariable analysis demonstrated that DNR status was independently associated with mortality (OR = 2.04, 95%CI: 1.46-2.86, P < 0.001). Additionally, analysis of the propensity score matched cohort demonstrated that DNR status was associated with a significant, but very small increased likelihood of post-operative complications (0.53 vs 0.43 complications per episode; OR = 1.21; 95%CI: 1.04-1.41, P = 0.004). Cardiopulmonary resuscitation and unplanned reintubation were significantly less likely in patients with DNR status.

While DNR status patients had higher rates of post-operative complications and mortality, DNR status itself was not otherwise associated with increased morbidity. DNR status appears to increase 30-d mortality via ceilings of care in keeping with a DNR status, including withholding reintubation and cardiopulmonary resuscitation.