Date of Award

January 2012

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Sanziana Roman

Subject Area(s)

Surgery, Epidemiology, Ethics


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.


This is an Open Access Thesis.

Open Access

This Article is Open Access