Date of Award

January 2012

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Sanziana Roman

Subject Area(s)

Surgery, Epidemiology, Ethics

Abstract

Surgical Patients with Do-Not-Resuscitate (DNR) Orders: An Analysis of Characteristics and Short-term Outcomes Among 8256 Patients

Hadiza S. Kazaure, Sanziana A. Roman, Julie Ann Sosa

Section of Endocrine Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT

Objective: Using data obtained from more than 120 hospitals participating in the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP, 2005-08), the characteristics and outcomes of patients who underwent surgery with a DNR order were examined.

Methods: Patients with a DNR order were matched by age and procedure, to those without a DNR order. The main outcomes of interest were occurrence of postoperative complication(s) and mortality ≤30 days of surgery. The χ2 test was used to analyze categorical variables and the Student's t and Wilcoxon tests were used for continuous variables. Multivariate logistic regression was performed to determine independent risk factors associated with mortality among DNR patients.

Results: There were 4128 DNR patients and 4128 age-matched and procedure-matched non-DNR patients in the study. Most DNR patients were white (81.5%), female (58.2%), and elderly (mean age, 79 years). Compared to non-DNR patients, DNR patients had a higher complication (26.4 vs. 31%, p<0.001) and mortality rate (8.4 vs. 23.1%, p<0.001). Nearly 63% of DNR patients underwent non-emergent procedures; they sustained a 16.6% mortality rate, which was 3-fold higher than that of non-DNR patients (p<0.001). After controlling for > 40 risk factors in multivariate analysis, DNR status remained independently associated with mortality (odds ratio 2.2, 95% confidence interval: 1.8-2.8, p<0.001). ASA class 3-5, age >65 years, and preoperative sepsis were among risk factors independently associated with mortality among DNR patients.

Conclusions: Surgical patients with DNR orders have significant comorbidities; many sustain postoperative complications, and nearly one in four die ≤30 days of surgery. DNR status appears to be an independent risk factor for poor surgical outcome.

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This is an Open Access Thesis.

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