1
|
Devinney MJ, Treggiari MM. The role of Advance Directives and Living Wills in Anesthesia Practice. Anesthesiol Clin 2024; 42:377-392. [PMID: 39054014 DOI: 10.1016/j.anclin.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Preoperative review of existing advance directives and a discussion of patient goals should be routinely done to address any potential limitations on resuscitative therapies during perioperative care. Both surgeons and anesthesiologists should be collaboratively involved in these discussions, and all perioperative physicians should receive training in shared decision making and goals of care discussions. These discussions should center around patient preferences for limitations on life-sustaining medical therapy, which should be accurately documented and adhered to during the perioperative period. Patients should be informed that limitations of life-sustaining medical therapy may increase their risk of postoperative mortality.
Collapse
Affiliation(s)
- Michael J Devinney
- Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA; Department of Anesthesiology, Duke University School of Medicine, 40 Medicine Circle, Room 4317, Orange Zone, Duke Hospital South, Durham, NC 27710, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA; Department of Anesthesiology, Duke University School of Medicine, 3 Genome Court, MSRB-3, 6116, Durham, NC 27710, USA.
| |
Collapse
|
2
|
Driggers KE, Keenan LM, Alcover KC, Atkin M, Irby K, Kovacs M, McLawhorn MM, Mir-Kasimov M, Sabbahi WZ, Sellman J, Johnson LS. Unintended Consequences of Code Status in the Intensive Care Unit: What Happens After a Do-Not-Resuscitate Order Is Placed? A Retrospective Cohort Study. J Palliat Med 2024; 27:508-514. [PMID: 38574337 DOI: 10.1089/jpm.2023.0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
Background: Some clinicians suspect that patients with do-not-resuscitate (DNR) orders receive less aggressive care. Extrapolation from code status to goals of care could cause significant harm. This study asked the question: Do DNR orders in the intensive care unit (ICU) lead to a decrease in invasive interventions? Methods: This was a retrospective cohort study of ICU patients from three teaching hospitals. All ICU patients were assessed for inclusion. Exclusion criteria were medical futility and death, comfort care, or ICU discharge <48 hours after DNR initiation. Five hundred thirty-six patients met inclusion criteria. One hundred forty-five were included in the final analysis. Primary outcomes were occurrence of invasive interventions after DNR initiation-surgical operation, central line, ventilation, dialysis, or other procedure. Secondary outcomes were antibiotic administration, blood transfusion, mortality, and discharge location. Results: Patients with DNR orders underwent fewer surgical operations (14.5% vs. 31.1%, p = 0.002), but more central lines (42.1% vs. 23.0%, p = 0.009), ventilator use (49.0% vs. 18.9%, p < 0.001), and dialysis (20.0% vs. 4.1%, p = 0.002), compared with patients without DNR orders. Transfusions and antibiotic use decreased similarly over admission for both groups (transfusions: β = 1.25; p = 0.59; and antibiotics: β = 1.44; p = 0.27). Mortality and hospice discharges were higher for DNR patients (p < 0.001.). Conclusions: DNR status did not decrease the number of nonoperative interventions patients received as compared with full code counterparts. Although differences in populations existed, patients with DNR orders were likely to receive a similar number of invasive interventions. This finding suggests that providers do not wholesale limit these options for patients with code status limitations.
Collapse
Affiliation(s)
- Kathryn E Driggers
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Lynn M Keenan
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Pulmonary and Critical Care Medicine, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Karl C Alcover
- Department of Medicine, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Megan Atkin
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kathleen Irby
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Monique Kovacs
- Pulmonary and Critical Care Medicine, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Melissa M McLawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - Mustafa Mir-Kasimov
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Pulmonary and Critical Care Medicine, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Wesam Z Sabbahi
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jeffrey Sellman
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Pulmonary and Critical Care Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Laura S Johnson
- Department of Medicine, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Surgery, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC, USA
- Walter L. Ingram Burn Center at Grady Memorial Hospital, Atlanta, Georgia, USA
- Department of Surgery, Emory Universiy School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
3
|
Wells CI, Bhat S, Xu W, Varghese C, Keane C, Baraza W, O'Grady G, Harmston C, Bissett IP. Variation in the definition of 'failure to rescue' from postoperative complications: a systematic review and recommendations for outcome reporting. Surgery 2024; 175:1103-1110. [PMID: 38245447 DOI: 10.1016/j.surg.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 11/14/2023] [Accepted: 12/12/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Failure to rescue is the rate of death amongst patients with postoperative complications and has been proposed as a perioperative quality indicator. However, variation in its definition has limited comparisons between studies. We systematically reviewed all surgical literature reporting failure to rescue rates and examined variations in the definition of the 'numerator,' 'denominator,' and timing of failure to rescue measurement. METHODS Databases were searched from inception to 31 December 2022. All studies reporting postoperative failure to rescue rates as a primary or secondary outcome were included. We examined the complications included in the failure to rescue denominator, the percentage of deaths captured by the failure to rescue numerator, and the timing of measurement for complications and mortality. RESULTS A total of 359 studies, including 212,048,069 patients, were analyzed. The complications included in the failure to rescue denominator were reported in 295 studies (82%), with 131 different complications used. The median number of included complications per study was 10 (interquartile range 8-15). Studies that included a higher number of complications in the failure-to-rescue denominator reported lower failure-to-rescue rates. Death was included as a complication in the failure to rescue the denominator in 65 studies (18%). The median percentage of deaths captured by the failure to rescue calculation when deaths were not included in the denominator was 79%. Complications (52%) and mortality (40%) were mostly measured in-hospital, followed by 30-days after surgery. CONCLUSION Failure to rescue is an important concept in the study of postoperative outcomes, although its definition is highly variable and poorly reported. Researchers should be aware of the advantages and disadvantages of different approaches to defining failure to rescue.
Collapse
Affiliation(s)
- Cameron I Wells
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand.
| | - Sameer Bhat
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora MidCentral, Palmerston North, New Zealand
| | - William Xu
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Tai Tokerau, Whangārei, New Zealand
| | - Chris Varghese
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of General Surgery, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Celia Keane
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Tai Tokerau, Whangārei, New Zealand
| | - Wal Baraza
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
| | - Chris Harmston
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Tai Tokerau, Whangārei, New Zealand
| | - Ian P Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
| |
Collapse
|
4
|
Brovman EY, Motejunas MW, Bonneval LA, Whang EE, Kaye AD, Urman RD. Relationship Between Newly Established Perioperative DNR Status and Perioperative Outcomes in the Elderly Population: A NSQIP Database Analysis. J Palliat Care 2024; 39:97-104. [PMID: 32718256 DOI: 10.1177/0825859720944746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Background: Health care practitioners have developed complex algorithms to numerically calculate surgical risk. We examined the association between the initiation of a new do-not-resuscitate (DNR) status during hospitalization and postoperative outcomes, including mortality. We hypothesized that new DNR status would be associated with similar complication rates, even though mortality rates may be higher. Methods: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Research File. Two cohorts were defined by the presence of a new DNR status during the hospitalization that was not present on hospital admission. Multivariable logistic regression was used to control for differences between the DNR and non-DNR cohorts. The primary outcome was 30-day mortality. Secondary outcomes included rates of postoperative complications, including returning to the operating room, reintubation, failure to wean from ventilation, surgical site infections, dehiscence, pneumonia, acute kidney injury, renal failure, stroke, cardiac arrest, acute myocardial infarction, transfusion requirements, sepsis, urinary tract infections, venous thromboembolisms, total number of complications for each patient, and hospital length of stay. Results: In our geriatric population with a newly established DNR status, the mortality rate was 39.29%, significantly greater than the non-DNR population after multivariable regression. Secondary outcomes also occurred at an increased rate in the DNR cohort including surgical site infections (8.29% vs 4.04%), pneumonia (18% vs 2.26%), renal insufficiency (2.43% vs 0.35%), acute renal failure (5% vs 0.19%), stroke (3% vs 0.36%), acute myocardial infarction (6.29% vs 0.95%), and cardiac arrest (5.86% vs 0.51%). Conclusions: The initiation of a new DNR status during hospitalization is associated with a significantly higher burden of both morbidity and mortality. This contrasts with prior studies that did not show an increased rate of adverse outcomes and suggests that a new DNR status in postoperative patients may reflect a consequence of adverse postoperative events. The informed consent process in older patients at risk for adverse outcomes after surgery should include discussions regarding goals of care and acceptable risk.
Collapse
Affiliation(s)
- Ethan Y Brovman
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Mark W Motejunas
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Lauren A Bonneval
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Edward E Whang
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
5
|
Tanious M, Lindvall C, Cooper Z, Tukan N, Peters S, Streid J, Fields K, Bader A. Prevalence, Management, and Outcomes Related to Preoperative Medical Orders for Life Sustaining Treatment (MOLST) in an Adult Surgical Population: Preoperative MOLST and Code Status Discussions. Ann Surg 2023; 277:109-115. [PMID: 33351480 DOI: 10.1097/sla.0000000000004675] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine prevalence of documented preoperative code status discussions and postoperative outcomes (specifically mortality, readmission, and discharge disposition) of patients with completed MOLST forms before surgery. SUMMARY OF BACKGROUND DATA A MOLST form documents patient care preference regarding treatment limitations. When considering surgery in these patients, preoperative discussion is necessary to ensure concordance of care. Little is known about prevalence of these discussions and postoperative outcomes. METHODS A retrospective cohort study was conducted consisting of all patients having surgery during a 1-year period at a tertiary care academic center in Boston, Massachusetts. RESULTS Among 21,787 surgical patients meeting inclusion criteria, 402 (1.8%) patients had preoperative MOLST. Within the MOLST, 224 (55.7%) patients had chosen to limit cardiopulmonary resuscitation and 214 (53.2%) had chosen to limit intubation and mechanical ventilation. Code status discussion was documented presurgery in 169 (42.0%) patients with MOLST. Surgery was elective or nonurgent for 362 (90%), and median length of stay (Q1, Q3) was 5.1 days (1.9, 9.9). The minority of patients with preoperative MOLST were discharged home [169 (42%), and 103 (25.6%) patients were readmitted within 30 days. Patients with preoperative MOLST had a 30-day mortality of 9.2% (37 patients) and cumulative 90-day mortality of 14.9% (60 patients). CONCLUSIONS Fewer than half of surgical patients with preoperative MOLST have documented code status discussions before surgery. Given their high risk of postoperative mortality and the diversity of preferences found in MOLST, thoughtful discussion before surgery is critical to ensure concordant perioperative care.
Collapse
Affiliation(s)
- Mariah Tanious
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina
| | - Charlotta Lindvall
- Department of Palliative Medicine, Dana Farber Cancer Institute, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Department of Palliative Medicine, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Natalie Tukan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Peters
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jocelyn Streid
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kara Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Angela Bader
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
6
|
Hao Q, Segel JE, Gusani NJ, Hollenbeak CS. Do-Not-Resuscitate Orders and Outcomes for Patients with Pancreatic Cancer. J Pancreat Cancer 2022; 8:15-24. [PMID: 36583027 PMCID: PMC9786086 DOI: 10.1089/pancan.2022.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 11/07/2022] Open
Abstract
Background The impact of the do-not-resuscitate (DNR) order on patients with pancreatic cancer remains uncertain. In this study, we evaluated whether DNR status was associated with in-hospital mortality and costs for inpatient stay among patients hospitalized with pancreatic cancer. Methods Data were obtained from the National Inpatient Sample, Healthcare Cost and Utilization Project, which represents ∼20% of all discharges from US community hospitals; 40,246 pancreatic cancer admissions between 2011 and 2016 were included. Mortality was modeled using a logistic regression model; costs for inpatient stay were modeled using a multivariable generalized linear regression model. Results The sample included 6041 (15%) patients with a documented DNR order. After controlling for covariates, patients with a DNR order had approximately six times greater odds of mortality compared with patients without a DNR order (odds ratio 5.90, p < 0.0001). Compared with patients who survived without a DNR order during the hospital stay, patients who had a DNR order and died during the hospital stay had significantly lower costs (-US$983; p = 0.0270), and patients who died without a DNR order during the hospital stay had significantly higher costs (US$5638; p < 0.0001). Patients who survived with a DNR order had costs that were not significantly different from patients who survived without a DNR order. Conclusions The presence of a DNR order among patients with pancreatic cancer was significantly associated with higher mortality risk as well as lower costs for patients who died during the hospital stay. However, DNR status was not significantly associated with costs for pancreatic cancer patients who were discharged alive.
Collapse
Affiliation(s)
- Qiang Hao
- Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, USA.,Address correspondence to: Qiang Hao, PhD-C, Department of Health Policy Administration, Pennsylvania State University, 501F Ford Building, University Park, PA 16802, USA.
| | - Joel E. Segel
- Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, USA.,Penn State Cancer Institute, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Niraj J. Gusani
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA.,Section of Surgical Oncology, Division of Surgery, Baptist MD Anderson Cancer Center, Jacksonville, Florida, USA
| | - Christopher S. Hollenbeak
- Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA.,Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| |
Collapse
|
7
|
Driggers KE, Dishman SE, Chung KK, Olsen CH, Ryan AB, McLawhorn MM, Johnson LS. Perceptions of care following initiation of do-not-resuscitate orders. J Crit Care 2022; 69:154008. [DOI: 10.1016/j.jcrc.2022.154008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 01/29/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022]
|
8
|
Shah S, Makhnevich A, Cohen J, Zhang M, Marziliano A, Qiu M, Liu Y, Diefenbach MA, Carney M, Burns E, Sinvani L. Early DNR in Older Adults Hospitalized with SARS-CoV-2 Infection During Initial Pandemic Surge. Am J Hosp Palliat Care 2022; 39:1491-1498. [PMID: 35510776 DOI: 10.1177/10499091221084653] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The role of early Do Not Resuscitate (DNR) in hospitalized older adults (OAs) with SARS-CoV-2 infection is unknown. The objective of the study was to identify characteristics and outcomes associated with early DNR in hospitalized OAs with SARS-CoV-2. We conducted a retrospective chart review of older adults (65+) hospitalized with COVID-19 in New York, USA, between March 1, 2020, and April 20, 2020. Patient characteristics and hospital outcomes were collected. Early DNR (within 24 hours of admission) was compared to non-early DNR (late DNR, after 24 hours of admission, or no DNR). Outcomes included hospital morbidity and mortality. Of 4961 patients, early DNR prevalence was 5.7% (n = 283). Compared to non-early DNR, the early DNR group was older (85.0 vs 76.8, P < .001), women (51.2% vs 43.6%, P = .012), with higher comorbidity index (3.88 vs 3.36, P < .001), facility-based (49.1% vs 19.1%, P < .001), with dementia (13.3% vs 4.6%, P < .001), and severely ill on presentation (57.9% vs 32.3%, P < .001). In multivariable analyses, the early DNR group had higher mortality risk (OR: 2.94, 95% CI: 2.10-4.11), less hospital delirium (OR: 0.55, 95% CI: 0.40-.77), lower use of invasive mechanical ventilation (IMV, OR: 0.37, 95% CI: .21-.67), and shorter length of stay (LOS, 4.8 vs 10.3 days, P < .001), compared to non-early DNR. Regarding early vs late DNR, while there was no difference in mortality (OR: 1.12, 95% CI: 0.85-1.62), the early DNR group experienced less delirium (OR: 0.55, 95% CI: .40-.75), IMV (OR: 0.53, 95% CI: 0.29-.96), and shorter LOS (4.82 vs 10.63 days, OR: 0.35, 95% CI: 0.30-.41). In conclusion, early DNR prevalence in hospitalized OAs with COVID-19 was low, and compared to non-early DNR is associated with higher mortality but lower morbidity.
Collapse
Affiliation(s)
- Shalin Shah
- Division of Hospital Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Alex Makhnevich
- Division of Hospital Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.,Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Jessica Cohen
- Division of Hospital Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Meng Zhang
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Allison Marziliano
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Michael Qiu
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Yan Liu
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Michael A Diefenbach
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Maria Carney
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.,Division of Geriatrics and Palliative Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA
| | - Edith Burns
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.,Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA.,Division of Geriatrics and Palliative Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA
| | - Liron Sinvani
- Division of Hospital Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.,Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| |
Collapse
|
9
|
The Impact of Do-Not-Resuscitate Order in the Emergency Department on Respiratory Failure after ICU Admission. Healthcare (Basel) 2022; 10:healthcare10030434. [PMID: 35326912 PMCID: PMC8956014 DOI: 10.3390/healthcare10030434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/04/2022] Open
Abstract
(1) Background: It has been hypothesized that a discrepancy exists in the understanding of a do-not-resuscitate (DNR) order among physicians. We hypothesized that a DNR order signed in the emergency department (ED) could influence the patients’ prognosis after intensive care unit (ICU) admission. (2) Methods: We included patients older than 17 years, who visited the emergency department for non-traumatic disease, who had respiratory failure, required ventilator support, and were admitted to the ICU between January 2010 and December 2016. The associations between DNR and mortality, hospital length of stay (LOS), and medical fees were analyzed. Prolonged hospital LOS was defined as hospital stay ≥75th percentile (≥26 days for the study). Patients were classified as those who did and did not sign a DNR order. A 1:4 propensity score matching was conducted for demographics, comorbidities, and etiology. (3) Results: The study enrolled a total of 1510 patients who signed a DNR and 6040 patients who did not sign a DNR. The 30-day mortality rates were 47.4% and 28.0% among patients who did and did not sign a DNR, respectively. A DNR order was associated with mortality after adjusting for confounding factors (hazard ratio, 1.9; confidence interval, 1.70−2.03). It was also a risk factor for prolonged hospital LOS in survivors (odds ratio, 1.2; confidence interval, 1.02−1.44). Survivors who signed a DNR order were charged higher medical fees than those who did not sign a DNR (217,159 vs. 245,795 New Taiwan Dollars, p < 0.001). (4) Conclusions: Signing a DNR order in the ED increased the ICU mortality rate among patients who had respiratory failure and needed ventilator support. It increased the risk of prolonged hospital LOS among survivors. Finally, signing a DNR order was associated with high medical fees among survivors.
Collapse
|
10
|
Cushman T, Waisel DB, Treggiari MM. The Role of Anesthesiologists in Perioperative Limitation of Potentially Life-Sustaining Medical Treatments: A Narrative Review and Perspective. Anesth Analg 2021; 133:663-675. [PMID: 34014183 DOI: 10.1213/ane.0000000000005559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
No patient arrives at the hospital to undergo general anesthesia for its own sake. Anesthesiology is a symbiont specialty, with the primary mission of preventing physical and psychological pain, easing anxiety, and shepherding physiologic homeostasis so that other care may safely progress. For most elective surgeries, the patient-anesthesiologist relationship begins shortly before and ends after the immediate perioperative period. While this may tempt anesthesiologists to defer goals of care discussions to our surgical or primary care colleagues, we have both an ethical and a practical imperative to share this responsibility. Since the early 1990s, the American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA), and the Association of Perioperative Registered Nurses (AORN) have mandated a "required reconsideration" of do-not-resuscitate (DNR) orders. Key ethical considerations and guiding principles informing this "required reconsideration" have been extensively discussed in the literature and include respect for patient autonomy, beneficence, and nonmaleficence. In this article, we address how well these principles and guidelines are translated into daily clinical practice and how often anesthesiologists actually discuss goals of care or potential limitations to life-sustaining medical treatments (LSMTs) before administering anesthesia or sedation. Having done so, we review how often providers implement goal-concordant care, that is, care that reflects and adheres to the stated patient wishes. We conclude with describing several key gaps in the literature on goal-concordance of perioperative care for patients with limitations on LSMT and summarize novel strategies and promising efforts described in recent literature to improve goal-concordance of perioperative care.
Collapse
Affiliation(s)
- Tera Cushman
- From the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - David B Waisel
- Department of Anesthesiology, Yale University, New Haven, Connecticut
| | | |
Collapse
|
11
|
Krishnan S, Brovman EY, Urman RD. Preoperative Cognitive Impairment as a Perioperative Risk Factor in Patients Undergoing Total Knee Arthroplasty. Geriatr Orthop Surg Rehabil 2021; 12:21514593211004533. [PMID: 35186420 PMCID: PMC8848037 DOI: 10.1177/21514593211004533] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/02/2021] [Indexed: 12/21/2022] Open
Abstract
Background: The study assessed whether pre-existing cognitive impairment (CI) prior to elective total knee arthroplasty (TKA) is associated with worse postoperative outcomes such as delirium, in-hospital medical complications, 30-day mortality, hospital length of stay and non-home discharge. Methods: A retrospective database analysis from the NSQIP Geriatric Surgery Pilot Project was used. There was an initial cohort of 6350 patients undergoing elective TKA, 104 patients with CI were propensity score matched to 104 patients without CI. Results: Analysis demonstrated a significantly increased incidence of post-operative delirium (POD) in the cohort with pre-op CI (p = < .001), a worsened functional status (p = < .001) and increased nonhome discharge postoperatively compared to the group without CI (p = 0.029). Other post-operative outcomes included 30-day mortality of 0% in both groups, and low rate of complications such as infection (2.88% vs 0.96%), pneumonia (1.92% vs 0%), failure to wean (0.96% vs 0%), and reintubation (0.96% vs 0%). Some other differences between the CI group and non-CI group, although not statistically significant, included increased rate of transfusion (10.58% vs 6.73%), and sepsis (1.92% vs 0%). The length of stay was increased in the non-CI group (4.28% vs 2.32%, p = 0.122). Conclusion: CI in patients undergoing TKA is associated with an increased risk of POD, worsened postoperative functional status, and discharge to non-home facility.
Collapse
Affiliation(s)
- Sindhu Krishnan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ethan Y. Brovman
- Center for Perioperative Research, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Center for Perioperative Research, Brigham and Women’s Hospital, Boston, MA, USA
| |
Collapse
|
12
|
The Do Not Resuscitate (DNR) order in the perioperative setting: practical considerations. Curr Opin Anaesthesiol 2021; 34:141-144. [PMID: 33630773 DOI: 10.1097/aco.0000000000000974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW Addressing patients' Do Not Resuscitate (DNR) status in the perioperative setting is important for shared patient decision-making. Although the inherently resuscitative nature of anesthesia and surgery may pose an ethical quandary for clinicians tasked with caring for the patient, anesthesiologist-led efforts need to evaluate all aspects of the DNR order and operative procedures. RECENT FINDINGS Approximately 15% of patients undergoing surgical procedures have a preexisting DNR order (Margolis et al., 1995) [1]. American Society of Anesthesiologists (ASA) and the American College of Surgeons (ACS) do not support automatic reversal of the DNR order in the perioperative setting. Citing patient self-determination and autonomy, these societies advocate for a thoughtful discussion where a patient or legal designee may make an informed decision regarding resuscitation in the perioperative setting. Although studies have suggested increased perioperative mortality among patients with a preexisting DNR order, this data remains largely inconclusive. SUMMARY Efforts must be made to address the DNR order in the perioperative setting. The fundamental tenets of medical ethics, nonmaleficence, beneficence, and patient autonomy can help to guide this oftentimes challenging discussion.
Collapse
|
13
|
Cobert J, Lerebours R, Peskoe SB, Gordee A, Truong T, Krishnamoorthy V, Raghunathan K, Mureebe L. Exploring Factors Associated With Morbidity and Mortality in Patients With Do-Not-Resuscitate Orders: A National Surgical Quality Improvement Program Database Analysis Within Surgical Groups. Anesth Analg 2021; 132:512-523. [PMID: 33369926 DOI: 10.1213/ane.0000000000005311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Anesthesiologists caring for patients with do-not-resuscitate (DNR) orders may have ethical concerns because of their resuscitative wishes and may have clinical concerns because of their known increased risk of morbidity/mortality. Patient heterogeneity and/or emphasis on mortality outcomes make previous studies among patients with DNR orders difficult to interpret. We sought to explore factors associated with morbidity and mortality among patients with DNR orders, which were stratified by surgical subgroups. METHODS Exploratory retrospective cohort study in adult patients undergoing prespecified colorectal, vascular, and orthopedic surgeries was performed using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File data from 2010 to 2013. Among patients with preoperative DNR orders (ie, active DNR order written in the patient's chart before surgery), factors associated with 30-day mortality, increased length of stay, and inpatient death were determined via penalized regression. Unadjusted and adjusted estimates for selected variables are presented. RESULTS After selection as above, 211,420 patients underwent prespecified procedures, and of those, 2755 (1.3%) had pre-existing DNR orders and met above selection to address morbidity/mortality aims. By specialty, of these patients with a preoperative DNR, 1149 underwent colorectal, 870 vascular, and 736 orthopedic surgery. Across groups, 36.2% were male and had a mean age 79.9 years (range 21-90). The 30-day mortality was 15.4%-27.2% and median length of stay was 6-12 days. Death at discharge was 7.0%, 13.1%, and 23.0% in orthopedics, vascular, and colorectal patients with a DNR, respectively. The strongest factors associated with increased odds of 30-day mortality were preoperative septic shock in colorectal patients, preoperative ascites in vascular patients, and any requirement of mechanical ventilation at admission in orthopedic patients. CONCLUSIONS In patients with DNR orders undergoing common surgical procedures, the association of characteristics with morbidity and mortality varies in both direction and magnitude. The DNR order itself should not be the defining measure of risk.
Collapse
Affiliation(s)
- Julien Cobert
- Division of Critical Care Medicine, Department of Anesthesia, University of California at San Francisco, San Francisco, California.,Critical Care and Perioperative Epidemiology Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Reginald Lerebours
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Sarah B Peskoe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Alexander Gordee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Epidemiology Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- Critical Care and Perioperative Epidemiology Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.,Department of Anesthesiology, Durham Veterans Affairs Hospital, Durham, North Carolina
| | - Leila Mureebe
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.,Department of Surgery, Duke Surgical Center for Outcomes Research (SCORES), Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
14
|
Abstract
Although do-not-resuscitate orders only prohibit cardiopulmonary resuscitation in the case of cardiac arrest, the common initiation of this code status in the context of end-of-life care may lead providers to draw premature conclusions about other goals of care. The aim of this study is to identify concerns regarding care quality in the setting of do-not-resuscitate orders within the Department of Defense and compare differences in perceptions between members of the critical care team. Design A cross sectional observational study was conducted. Setting This study took place in the setting of critical care within the Department of Defense. Subjects All members of the Uniformed Services Section of the Society of Critical Care Medicine were invited to participate. Interventions A validated 31-question survey exploring the perceptions of care quality in the setting of do-not-resuscitate status was distributed. Measurements and Main Results Exploratory factor analysis was used to categorically group survey questions, and average factor scores were compared between respondent groups using t tests. Responses to individual questions were also analyzed between comparison groups using Fisher exact tests. Factor analysis revealed no significant differences between respondents of different training backgrounds; however, those with do-not-resuscitate training were more likely to agree that active treatment would be pursued (p = 0.024) and that trust and communication would be maintained (p = 0.005). Although 38% of all respondents worry that quality of care will decrease, 93% agree that life-prolonging treatments should be offered. About a third of providers wrongly believed that a do-not-resuscitate order must be reversed prior to an operation. Conclusions Although providers across training backgrounds held similar concerns about decreased care quality in the ICU, there is wide belief that the routine and noninvasive interventions are offered as indicated. Those with do-not-resuscitate training were more likely to believe that standards of care continued to be met after code status change.
Collapse
|
15
|
Hardin J, Forshier B. Adult Perianesthesia Do Not Resuscitate Orders: A Systematic Review. J Perianesth Nurs 2019; 34:1054-1068.e18. [PMID: 31230930 DOI: 10.1016/j.jopan.2019.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/12/2019] [Accepted: 03/23/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this systematic review is to assess if Do Not Resuscitate (DNR) orders should be routinely rescinded during anesthesia, determine if consensus on retaining DNR orders exists in the literature, and explore the current state of clinical practice. DESIGN This systematic review followed preferred reporting items for systematic reviews and meta-analyses guidelines. METHODS In June 2018, the Cumulative Index to Nursing and Allied Health Literature and PubMed databases were systematically searched using defined inclusion/exclusion criteria. FINDINGS Ninety-one articles from the databases were pooled with 16 works identified as formative to the research questions. Forty-nine articles were analyzed and included in this study. CONCLUSIONS It is unethical to automatically rescind DNR orders during anesthesia. Patients have the right to retain their DNR orders unaltered or modify them for the perianesthesia period. Sufficient evidence exists to create meaningful policy at every level. A consensus exists among professional organizations that the standard of care is a required reconsideration of DNR orders before anesthesia.
Collapse
|
16
|
Improving Preoperative Completion of Advanced Care Planning Documents in Patients With Expected Postoperative Intensive Care Unit Stay. A A Pract 2019; 12:455-458. [DOI: 10.1213/xaa.0000000000000993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
17
|
Quinn TD, Wolczynski P, Sroka R, Urman RD. Creating a Pathway for Multidisciplinary Shared Decision-Making to Improve Communication During Preoperative Assessment. Anesthesiol Clin 2018; 36:653-662. [PMID: 30390785 DOI: 10.1016/j.anclin.2018.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Shared decision-making (SDM) is essential for high-quality surgical care. Barriers to SDM exist in clinical practice but there is evidence these obstacles can be overcome. SDM requires clinician and patient engagement. Though patients may indicate understanding, deficits in decision making may persist based on language, age, or educational barriers. Multidisciplinary decision-making before surgery is an opportunity for anesthesiologists and other perioperative professionals to improve surgical care. The authors present an example of a successfully implemented pathway for high-risk surgical patients at a tertiary care center, leveraging the preoperative anesthesia evaluation.
Collapse
Affiliation(s)
- Timothy D Quinn
- Department of Anesthesiology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, 77 Goodell Street, Suite 550, Buffalo, NY 14203, USA; Department of Anesthesiology, Critical Care and Pain Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA.
| | - Piotr Wolczynski
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, 462 Grider Street, Buffalo, NY 14215, USA
| | - Raymond Sroka
- Department of Anesthesiology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, 77 Goodell Street, Suite 550, Buffalo, NY 14203, USA; Department of Anesthesiology, Critical Care and Pain Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Center for Perioperative Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| |
Collapse
|
18
|
Urman RD, Lilley EJ, Changala M, Lindvall C, Hepner DL, Bader AM. A Pilot Study to Evaluate Compliance with Guidelines for Preprocedural Reconsideration of Code Status Limitations. J Palliat Med 2018; 21:1152-1156. [DOI: 10.1089/jpm.2017.0601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Richard D. Urman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Perioperative Research, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth J. Lilley
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Marguerite Changala
- School of Medicine, University of California San Francisco, San Francisco, California
| | - Charlotta Lindvall
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - David L. Hepner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Angela M. Bader
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
19
|
Postoperative outcomes in patients with a do-not-resuscitate (DNR) order undergoing elective procedures. J Clin Anesth 2018; 48:81-88. [DOI: 10.1016/j.jclinane.2018.05.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 12/18/2022]
|
20
|
Bader AM. Defining and Ensuring Multidisciplinary High-Quality Patient-Centered Shared Decision-Making for Procedures: a Brief Review of the Current State. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0257-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
21
|
Brovman EY, Pisansky AJ, Beverly A, Bader AM, Urman RD. Do-Not-Resuscitate status as an independent risk factor for patients undergoing surgery for hip fracture. World J Orthop 2017; 8:902-912. [PMID: 29312849 PMCID: PMC5745433 DOI: 10.5312/wjo.v8.i12.902] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/30/2017] [Accepted: 11/30/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine morbidity and mortality in hip fracture patients and also to assess for any independent associations between Do-Not-Resuscitate (DNR) status and increased post-operative morbidity and mortality in patients undergoing surgical repair of hip fractures.
METHODS We conducted a propensity score matched retrospective analysis using de-identified data from the American College of Surgeons’ National Surgical Quality Improvement Project (ACS NSQIP) for all patients undergoing hip fracture surgery over a 7 year period in hospitals across the United States enrolled in the ACS NSQIP with and without DNR status. We measured patient demographics including DNR status, co-morbidities, frailty and functional baseline, surgical and anaesthetic procedure data, post-operative morbidity/complications, length of stay, discharge destination and mortality.
RESULTS Of 9218 patients meeting the inclusion criteria, 13.6% had a DNR status, 86.4% did not. Mortality was higher in the DNR compared to the non-DNR group, at 15.3% vs 8.1% and propensity score matched multivariable analysis demonstrated that DNR status was independently associated with mortality (OR = 2.04, 95%CI: 1.46-2.86, P < 0.001). Additionally, analysis of the propensity score matched cohort demonstrated that DNR status was associated with a significant, but very small increased likelihood of post-operative complications (0.53 vs 0.43 complications per episode; OR = 1.21; 95%CI: 1.04-1.41, P = 0.004). Cardiopulmonary resuscitation and unplanned reintubation were significantly less likely in patients with DNR status.
CONCLUSION While DNR status patients had higher rates of post-operative complications and mortality, DNR status itself was not otherwise associated with increased morbidity. DNR status appears to increase 30-d mortality via ceilings of care in keeping with a DNR status, including withholding reintubation and cardiopulmonary resuscitation.
Collapse
Affiliation(s)
- Ethan Y Brovman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Andrew J Pisansky
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Anair Beverly
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Angela M Bader
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States
- Center for Perioperative Research, Brigham and Women’s Hospital, Boston, MA 02115, United States
| |
Collapse
|
22
|
Defining and ensuring multidisciplinary high quality patient-centered shared decision making for procedures – A brief review of current state. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.pcorm.2017.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
23
|
Whitlock EL, Lane RK. Do Not Resuscitate and the Surgical Patient: Not a Contradiction in Terms. Anesth Analg 2017; 125:1438-1440. [PMID: 29049106 DOI: 10.1213/ane.0000000000002438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Elizabeth L Whitlock
- From the Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
| | | |
Collapse
|