Perioperative morbidity and mortality of cardiothoracic surgery in patients with a do-not-resuscitate order

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
DOI
10.7287/peerj.preprints.128v1
Subject Areas
Anesthesiology and Pain Management, Emergency and Critical Care, Palliative Care, Public Health, Surgery and Surgical Specialties
Keywords
DNR, do not resuscitate, do-not-resuscitate, do not attempt resuscitation, cardiothoracic surgery, morbidity and mortality, surgical mortality, advanced directive, OSHPD, PDD
Copyright
© 2013 Maxwell et al.
Licence
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Cite this article
Maxwell BG, Lobato RL, Cason MB, Wong JK. 2013. Perioperative morbidity and mortality of cardiothoracic surgery in patients with a do-not-resuscitate order. PeerJ PrePrints 1:e128v1

Abstract

Background: Do-not-resuscitate (DNR) orders are often active in patients with multiple comorbidities and a short natural life expectancy, but limited information exists as to how often these patients undergo high-risk operations and of the perioperative outcomes in this population. Methods: Using comprehensive inpatient administrative data from the Public Discharge Data file (years 2005 through 2010) of the California Office of Statewide Health Planning and Development, which includes a dedicated variable recording DNR status, we identified cohorts of DNR patients who underwent major cardiac or thoracic operations and compared them to age- and procedure-matched comparison cohorts. The primary study outcome was in-hospital mortality. Results: DNR status was not uncommon in cardiac (n=2,678, 1.1% of all admissions for cardiac surgery, age 71.6 ± 15.9 years) and thoracic (n=3,129, 3.7% of all admissions for thoracic surgery, age 73.8 ± 13.6 years) surgical patient populations. Relative to controls, patients who were DNR experienced significantly greater in-hospital mortality after cardiac (37.5% vs. 11.2%, p<0.0001) and thoracic (25.4% vs. 6.4%) operations. DNR status remained an independent predictor of in-hospital mortality on multivariate analysis after adjustment for baseline and comorbid conditions in both the cardiac (OR 4.78, 95% confidence interval 4.21-5.41, p<0.0001) and thoracic (OR 6.11, 95% confidence interval 5.37-6.94, p<0.0001) cohorts. Conclusions: DNR status is associated with worse outcomes of cardiothoracic surgery even when controlling for age, race, insurance status, and serious comorbid disease. DNR status appears to be a marker of substantial perioperative risk, and may warrant substantial consideration when framing discussions of surgical risk and benefit, resource utilization, and biomedical ethics surrounding end-of-life care.

Author Comment

This manuscript was submitted for review with PeerJ.

Supplemental Information

Characteristics of cardiac and thoracic DNR cohorts and matched controls

DOI: 10.7287/peerj.preprints.128v1/supp-1

Univariate analysis of outcomes in cardiac and thoracic DNR cohorts compared to matched controls

DOI: 10.7287/peerj.preprints.128v1/supp-2

Multivariate logistic regression models for in-hospital mortality

DOI: 10.7287/peerj.preprints.128v1/supp-3