Identifying high-risk surgical patients: A study of older adults whose code status changed to Do-Not-Resuscitate.
J Am Geriatr Soc
; 69(12): 3445-3456, 2021 12.
Article
em En
| MEDLINE
| ID: mdl-34331702
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.Palavras-chave
Texto completo:
1
Temas:
ECOS
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Equidade_desigualdade
Bases de dados:
MEDLINE
Assunto principal:
Procedimentos Cirúrgicos Operatórios
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Ordens quanto à Conduta (Ética Médica)
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Assistência Perioperatória
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Pacientes Internados
Tipo de estudo:
Etiology_studies
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Observational_studies
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Prognostic_studies
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Risk_factors_studies
Aspecto:
Equity_inequality
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Ethics
Limite:
Aged
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Aged80
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Female
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Humans
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Male
Idioma:
En
Revista:
J Am Geriatr Soc
Ano de publicação:
2021
Tipo de documento:
Article
País de afiliação:
Estados Unidos