Yale Study Links 'Do-Not-Resuscitate Orders' to Poor Surgical Outcomes & Higher Risk of Death

By Editor, on April 18th, 2011

A new study by Yale researchers published today in the Archives of Surgery, one of the JAMA journals of the American Medical Association, found that Do-Not-Resuscitate Orders were associated with poor surgical outcomes and a higher risk of death within 30 days after surgery, even for non-emergency procedures.

“Do-not-resuscitate (DNR) orders preclude the use of cardiopulmonary resuscitation (CPR) in a clinically unresponsive, pulseless patient,” according to background information provided by the study authors. According to a release issued by the JAMA Archives journals, approximately 70 percent of patients in the United States die with a DNR order. The study authors note that the use of DNR orders has been increasing, and now, up to 15 percent of patients with a DNR order have surgery.

The study, conducted by researchers from Yale University School of Medicine, New Haven, Conn., reviewed and analyzed data from the more than 120 hospitals that participated in the Quality Improvement Program of the American College of Surgeons from 2005 to 2008. The study population included 4,128 adult patients with DNR orders and 4,128 patients without DNR orders, who had similar procedures and were of the same age group as those with the DNR orders. The majority of the patients were white women (average age, 79 years).

The researchers measured and compared the extent of occurrence of one or more post-operative complications, re-operation, total time in the operating room and length of stay, and extent of death within 30 days after surgery among the patients who had DNR Orders as compared to those who did not have DNR Orders. 15.3 Percent of all of the patients in the study died within 30 days after surgery.

However, lead author Hadiza Kazaure, B.Sc. and his colleagues reported that, “Compared with non-DNR patients, more than twice as many DNR patients died within 30 days of surgery (8.4 percent vs 23.1 percent). The DNR patients were more likely to die regardless of the urgency of the surgical procedure (35.5 percent vs. 17.8 percent and 16.6 percent vs. 5.5 percent for emergent and non-emergent procedures, respectively).”

In fact, after adjustment for multiple risk factors, the authors found that patients with DNR orders were more likely to die after every procedure analyzed. They concluded that a DNR order was associated with significantly increased odds of death.

In addition, the researchers found that while the overall rate of post-operative complications among the study population was 28.6 percent, “[t]he DNR patients had higher complication rates than non-DNR patients (31 percent vs. 26.4 percent).”

“Patients with a DNR order consent to a variety of surgical procedures ranging from palliative surgery to aggressive attempts at extension of life. The goals of surgical interventions in such patients include gaining ‘additional time,’ improving quality of life, decreasing pain, or treating isolated problems, such as fracture,” according to the study authors.

“The DNR patients may have surgery to gain ‘additional time’; nevertheless, our study demonstrates that almost a quarter of DNR patients die within 30 days of surgery,” the authors write.

They conclude that, “Informed consent and elicitation of the goals of surgery, especially as they relate to overall goals of care, are essential for guiding surgical decisions involving DNR patients and their families. Issues pertaining to DNR status are complex, and they should be anticipated long before the 30-day period leading to an operation. Additional research is needed to evaluate the decision making of DNR patients with respect to undergoing surgery, particularly in the non-emergent setting, and the impact of a pre-operative DNR order on post-operative surgical care and to determine the long-term outcomes of DNR patients by procedure.”

The study is available online in the April 18, 2011 issue of the Archives of Surgery, a JAMA Archives journal of the American Medical Association.

For further information on DNR Orders, Health Care Advance Directives and related end-of-life issues, see our resource pages on: