title: Impact of "Do Not Resuscitate" Status on the Outcome of Major Vascular Surgical Procedures.
abstract: BACKGROUND
  Patients with Do Not Resuscitate (DNR) orders may still be offered surgery that aims to prolong or improve quality of life. The widely accepted approach of "required reconsideration" mandates that patients and surgeons discuss perioperative risks and expected outcomes in the context of the patient's values and preferences. However, surgical outcomes in this patient population have not been well-defined. The objectives of this study are to assess outcomes in DNR patients undergoing major vascular procedures, and develop an evidence basis for informed, shared decision-making.
  
  
  METHODS
  Patients undergoing common major vascular procedures were identified in the 2007-2010 National Surgical Quality Improvement Project databases. DNR patients were defined as those with an active DNR order within 30 days before surgery. Demographics, comorbidities, procedural details, and complications were compared with those without DNR orders. To isolate the impact of DNR status, multivariate regression and 1:1 propensity score matching were used to compare outcomes between DNR patients and a non-DNR cohort of comparably high-risk patients.
  
  
  RESULTS
  Of 110,279 patients undergoing major vascular surgery, 1,565 (1.4%) had active DNR orders 30 days preceding surgery. DNR patients were more likely to be functionally dependent (69% vs. 15%; P < 0.0001), over 80 years of age (53% vs. 20%; P < 0.001), and suffer from a variety of cardiac, pulmonary, and systemic comorbidities. The most common procedures in DNR patients were major amputation (38.4%), lower extremity bypass (20%), and peripheral thromboembolectomy (11.7%). Unadjusted 30-day mortality was significantly higher among DNR patients (21% vs. 3.4%; P < 0.001). After 1:1 propensity score matching, with the 2 cohorts differing only with respect to DNR status, perioperative mortality remained significantly higher among DNR patients (21% vs. 13%; P < 0.01). There was a trend toward reduced cardiopulmonary resuscitation in patients with recent DNR (1.7% vs. 2.6%; P = 0.07).
  
  
  CONCLUSIONS
  DNR patients are at high risk for major complications and mortality after vascular surgery procedures. Compared with a matched cohort of "high-risk" non-DNR patients, those with DNR orders suffered equivalent rates of postoperative morbidity, but markedly increased mortality. This suggests that DNR status, independent of comorbidities and perioperative complications, may increase the risk of "failure to rescue." These findings have implications not only for risk adjustment, but also provide an evidence basis for shared decision-making in challenging circumstances.
authors.affiliation: Division of Vascular and Endovascular Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY; Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA. Electronic address: jeffrey.siracuse@bmc.org.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Siracuse
authors.affiliation: Division of Vascular and Endovascular Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY; Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA.
authors.forename: Douglas W
authors.initials: DW
authors.lastname: Jones
authors.affiliation: Division of Medical Ethics, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY.
authors.forename: Ellen C
authors.initials: EC
authors.lastname: Meltzer
authors.affiliation: Division of Vascular and Endovascular Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY.
authors.forename: Ashley R
authors.initials: AR
authors.lastname: Graham
authors.affiliation: Division of Vascular and Endovascular Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY.
authors.forename: Gregory G
authors.initials: GG
authors.lastname: Salzler
authors.affiliation: Division of Vascular and Endovascular Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY.
authors.forename: Peter H
authors.initials: PH
authors.lastname: Connolly
authors.affiliation: Division of Vascular and Endovascular Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY.
authors.forename: Darren B
authors.initials: DB
authors.lastname: Schneider
authors.affiliation: Division of Vascular and Endovascular Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY; Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Meltzer
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation; D016009:Chi-Square Distribution; D015897:Comorbidity; D016208:Databases, Factual; D005260:Female; D006304:Health Status; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D057240:Patient Preference; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D057216:Propensity Score; D016414:Resuscitation Orders; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality