New Perioperative Do Not Resuscitate Orders: Exploring Risk Factors and Timing

Older adults undergoing surgery are at increased risk for postoperative complications, functional decline, and death, yet factors associated with new perioperative do not resuscitate (DNR) orders and the timing of these orders relative to clinical events remain incompletely defined.

Retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Program (2015-2019). Patients aged 65 years and older undergoing surgery at participating hospitals were included. The primary outcome was new perioperative DNR order within 30 days of surgery. Multivariable logistic regression accounting for hospital-level clustering identified predictors of new DNR placement. Timing analyses evaluated DNR placement relative to surgery, mortality, major morbidity, and palliative care consultation (PCC).

Among 47,564 cases from 27 sites, 1,108 (2.3%) had a new perioperative DNR order. Independent predictors included ASA IV/V (OR 2.6, 95% CI 1.9-3.6), disseminated cancer (OR 3.3, 95% CI 2.5-4.3), emergent surgery (OR 3.5, 95% CI 1.8-6.7), malnutrition (OR 2.3, 95% CI 1.6-3.1), and postoperative delirium (OR 2.3, 95% CI 1.8-2.9). PCC was associated with new DNR placement in cases with non-missing PCC data (OR 10.8, 95% CI 6.9-17.0). New DNR orders were placed a mean 3.8 (±7.0) days after surgery; 32.5% occurred within 24 hours of surgery. Among patients who died, DNR orders were placed a mean 5.2 (±6.6) days before death, with 43.3% occurring within 24 hours of death. Among 239 cases with both PCC and DNR dates, 46.4% occurred on the same day.

New perioperative DNR orders in older adults cluster early after surgery and near death. These patterns, together with low overall specialty PCC use, identify potential opportunities for earlier structured multidisciplinary goals-of-care discussions in high-risk surgical patients.