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Identifying high-risk surgical patients: A study of older adults whose code status changed to Do-Not-Resuscitate. Journal of the American Geriatrics Society Kazaure, H. S., Truong, T., Kuchibhatla, M., Lagoo-Deenadayalan, S., Wren, S. M., Johnson, K. S. 2021

Abstract

BACKGROUND: There is a paucity of data on older adults (age =65years) undergoing surgery who had an inpatient do-not-resuscitate (DNR) order, and the association between timing of DNR order and outcomes.METHODS: This was a retrospective analysis of 1976 older adults in the American College of Surgeons National Surgical Quality Improvement Program geriatric-specific database (2014-2018). Patients were stratified by institution of a DNR order during their surgical admission ("new-DNR" vs. "no-DNR"), and matched by age (±3years), frailty score (range: 0-1), and procedure. The main outcome of interest was occurrence of death or hospice transition (DoH) =30 postoperative days; this was analyzed using bivariate and multivariable methods.RESULTS: One in 36 older adults had a new-DNR order. After matching, there were 988 new-DNR and 988 no-DNR patients. Median age and frailty score were 82years and 0.2, respectively. Most underwent orthopedic (47.6%), general (37.6%), and vascular procedures (8.4%). Overall DoH rate =30days was 44.4% for new-DNR versus 4.0% for no-DNR patients (p<0.001). DoH rate for patients who had DNR orders placed in the preoperative, day of surgery, and postoperative setting was 16.7%, 23.3%, and 64.6%, respectively (p<0.001). In multivariable analysis, compared to no-DNR patients, those with a new-DNR order had a 28-fold higher adjusted odds of DoH (odds ratio [OR] 28.1, 95% confidence interval: 13.0-60.1, p<0.001); however, odds were 10-fold lower if the DNR order was placed preoperatively (OR: 5.8, p=0.003) versus postoperatively (OR: 52.9, p<0.001). Traditional markers of poor postoperative outcomes such as American Society of Anesthesiologists class and emergency surgery were not independently associated with DoH.CONCLUSIONS: An inpatient DNR order was associated with risk of DoH independent of traditional markers of poor surgical outcomes. Further research is needed to understand factors leading to a DNR order that may aid early recognition of high-risk older adults undergoing surgery.

View details for DOI 10.1111/jgs.17391

View details for PubMedID 34331702