Published online Dec 18, 2017. doi: 10.5312/wjo.v8.i12.902
Peer-review started: July 14, 2017
First decision: September 4, 2017
Revised: October 30, 2017
Accepted: November 28, 2017
Article in press: November 28, 2017
Published online: December 18, 2017
Relatively little is known about the exact mechanism through which Do-Not-Resuscitate (DNR) status affects patient outcomes during the perioperative period. The approach of surgical and anesthesia societies has been to treat DNR status as a component of the decision to undergo surgery or as a means of framing surgical goals and expectations with patients and their families. Depending on patients’ goals, DNR status may even be reversed during the perioperative period. However, little is known about how preoperative DNR status affects morbidity and mortality during the perioperative period, if at all.
Patients in the orthogeriatric population who are undergoing hip fracture fixation surgery may be at increased risk for morbidity and/or mortality. Given that these patients have already made a premeditated decision to limit cardiopulmonary resuscitative aspects of their medical care, they may also benefit from additional counselling with regard to any additional risks that may apply to their surgical population.
This study seeks to describe the incidence and distribution of DNR status in patients undergoing hip fracture surgery and to determine whether DNR status is an independent risk factor for worse outcomes on 30-d follow up. The study’s objective was realized by analysis of propensity matched groups of patients in a large retrospective cohort. The study seeks to support an emerging field of literature which describes the unique perioperative outcomes among patients with preoperative DNR/DNI status.
A large, national, US-based retrospective cohort database was used to identify patients undergoing surgical fixation for hip fracture across a variety of geographic and hospital settings. Characteristics of this cohort were examined for unmatched groups of patients with and without DNR/DNI orders, as well as for groups of matched on their propensity for having a DNR/DNI order.
This study demonstrates that when comparing groups of patients that have been matched on propensity for DNR/DNI status, having a DNR/DNI order was independently associated with mortality (OR = 2.04, 95%CI: 1.46-2.86, P < 0.001). Additionally, DNR/DNI status was associated with a very slight increased risk of perioperative complications without otherwise showing significantly different incidences of morbidity between the matched groups.
New findings contributed by this study include insight in the role of DNR/DNI status as an independent predictor of perioperative mortality among patients undergoing hip fracture fixation surgeries. Notably, these matched groups did not demonstrate associations between DNR/DNI status and perioperative morbidity. Given that rates of CPR and reintubation were markedly lower in the DNR/DNI group, we demonstrate that there may be a “ceilings of care” effect in this context. The findings also raises a question as to whether a “failure to rescue” mechanism may be active among these patients in the perioperative period. Regardless, the results of this study raise questions for future research which will hopefully yield additional insight into the mechanisms driving increased mortality among patients with DNR/DNI status who are undergoing surgery for hip fracture. In the immediate term, these findings will assist clinicians in appropriately counselling patients who may have a DNR/DNI order and are undergoing surgery for hip fracture.
Future research will hopefully yield additional insight into the mechanisms driving increased mortality among patients with DNR/DNI status who are undergoing surgery for hip fracture.