Identifying high-risk surgical patients: A study of older adults whose code status changed to Do-Not-Resuscitate

Hadiza S Kazaure; Tracy Truong; Maragatha Kuchibhatla; Sandhya Lagoo-Deenadayalan; Sherry M Wren; Kimberly S Johnson

doi:10.1111/jgs.17391

Identifying high-risk surgical patients: A study of older adults whose code status changed to Do-Not-Resuscitate

J Am Geriatr Soc. 2021 Dec;69(12):3445-3456. doi: 10.1111/jgs.17391. Epub 2021 Jul 31.

Authors

Hadiza S Kazaure¹, Tracy Truong², Maragatha Kuchibhatla², Sandhya Lagoo-Deenadayalan^{1

3

4}, Sherry M Wren⁵, Kimberly S Johnson^{3

4

6}

Affiliations

¹ Division of Surgical Oncology, Department of Surgery, Duke University, Durham, North Carolina, USA.
² Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA.
³ Department of Surgery, Durham VA Health Care System, Durham, North Carolina, USA.
⁴ Geriatrics Research Education and Clinical and Clinical Center, Durham, Virginia, USA.
⁵ Department of General Surgery, Stanford University School of Medicine, Stanford, California, USA.
⁶ Division of Geriatrics, Department of Medicine, Center for the Study of Aging and Human Development, Center for Palliative Care, Duke University School of Medicine, Durham, North Carolina, USA.

Abstract

Background: There is a paucity of data on older adults (age ≥65 years) 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 (±3 years), 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 82 years and 0.2, respectively. Most underwent orthopedic (47.6%), general (37.6%), and vascular procedures (8.4%). Overall DoH rate ≤30 days 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.

Keywords: do-not-resuscitate; frailty; geriatrics; hospice; outcomes; surgery.

Publication types

Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Aged, 80 and over
Databases, Factual
Female
Hospice Care / statistics & numerical data
Hospital Mortality
Humans
Inpatients / statistics & numerical data*
Male
Odds Ratio
Perioperative Care / mortality*
Resuscitation Orders*
Retrospective Studies
Risk Assessment
Surgical Procedures, Operative / mortality*
Time Factors

Grants and funding

UL1 TR002553/TR/NCATS NIH HHS/United States