Individualized approach to reconsider perioperative do-not-resuscitate orders in frail older patients

Accuracy of frailty instruments in predicting outcomes following perioperative cardiac arrest

BACKGROUND

Frailty is associated with increased 30-day mortality and non-home discharge following perioperative cardiac arrest. We estimated the predictive accuracy of frailty when added to baseline risk prediction models.

METHODS

In this retrospective cohort study using 2015-2020 NSQIP data for 3048 patients aged 50+ undergoing non-cardiac surgery and resuscitation on post-operative day 0 (i.e., intraoperatively or postoperatively on the day of surgery), baseline models including age, sex, ASA physical status, preoperative sepsis or septic shock, and emergent surgery were compared to models that added frailty indices, either RAI or mFI-5, to predict 30-day mortality and non-home discharge. Predictive accuracy was characterized by area under the receiver operating characteristic curve (AUC-ROC), integrated calibration index (ICI), and continuous net reclassification index (NRI).

RESULTS

1786 patients (58.6%) died in the study cohort within 30 days, and 38.6% of eligible patients experienced non-home discharge. The baseline model showed good discrimination (AUC-ROC 0.77 for 30-day mortality and 0.74 for non-home discharge). AUC-ROC and ICI did not significantly change after adding frailty for 30-day mortality or non-home discharge. Adding RAI significantly improved NRI for 30-day mortality and non-home discharge; however, the magnitude was small and difficult to interpret, given other results including false positive and negative rates showing no difference in predictive accuracy.

CONCLUSIONS

Incorporating frailty did not significantly improve predictive accuracy of models for 30-day mortality and non-home discharge following perioperative resuscitation. Thus, demonstrated associations between frailty and outcomes of perioperative resuscitation may not translate into improved predictive accuracy. When engaging patients in shared decision-making regarding do-not-resuscitate orders perioperatively, providers should acknowledge uncertainty in anticipating resuscitation outcomes.

Preoperative Code Status Discussion Workflows: Targets for Improvement in Multidisciplinary Pathways

CONTEXT

Discussion of perioperative code status is an important element of preoperative care and a component of the American College of Surgeons' Geriatric Surgery Verification (GSV) program. Evidence suggests code status discussions (CSDs) are not routinely performed and are inconsistently documented.

OBJECTIVES

Because preoperative decision making is a complex process spanning multiple providers, this study aims to utilize process mapping to highlight challenges associated with CSDs and inform efforts to improve workflows and implement elements of the GSV program.

METHODS

Using process mapping, we detailed workflows relating to (CSDs) for patients undergoing thoracic surgery and a possible workflow for implementing GSV standards for goals and decision-making.

RESULTS

We generated process maps for outpatient and day-of-surgery workflows relating to CSDs. In addition, we generated a process map for a potential workflow to address limitations and integrate GSV Standards for Goals and Decision Making.

CONCLUSION

Process mapping highlighted challenges associated with the implementation of multidisciplinary care pathways and indicated a need for centralization and consolidation of perioperative code status documentation.

Beyond the Do-not-resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients

American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, "full code" is the default option irrespective of clinical circumstances and patient preferences. It is time to revisit this approach based on (1) increasing understanding of the power of default options in healthcare settings, (2) changing demographics and growing evidence suggesting that an expanding subset of patients is vulnerable to poor outcomes after perioperative cardiopulmonary resuscitation (CPR), and (3) recommendations from multiple societies promoting risk assessment and goal-concordant care in older surgical patients. The authors reconsider current guidelines in the context of these developments and advocate for an expanded approach to decision-making regarding CPR, which involves identifying high-risk elderly patients and eliciting their preferences regarding CPR irrespective of existing or presumed code status.