Expectations and outcomes in geriatric patients with do-not-resuscitate orders undergoing emergency surgical management of bowel obstruction

Abstract

Objective: To describe the outcomes and the expected postoperative course for patients with do-not-resuscitate (DNR) orders (DNR patients) who undergo emergency surgical management of bowel obstruction.

Design: We retrospectively identified all patients who underwent emergency surgical management of intestinal obstruction and who were classified previously as DNR using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Participant Use Data File for 2005 through 2009. We constructed a forward stepwise multivariate logistic regression model to determine predictors of postoperative mortality. We used propensity score analysis to determine the effect of DNR status on postoperative outcomes.

Setting: Institutions participating in the NSQIP.

Patients: All patients entered in the NSQIP database.

Main outcome measures: Thirty-day postoperative mortality and complication rates.

Results: We identified 242 patients who met the study criteria. Mean age was 80.9 years. Thirty-day mortality was 29.8%, with 47.1% of patients experiencing a postoperative complication. The presence of a postoperative complication was an independent predictor of postoperative mortality. Comparison of matched cohorts revealed a significantly higher postoperative mortality in DNR patients even after adjusting for comorbidities and overall complication rate.

Conclusions: Outcomes are poor after emergency surgical intervention for bowel obstruction in elderly DNR patients, with high postoperative complication and mortality rates. The presence of a DNR order is an independent risk factor for postoperative mortality. Patients, their families, and their physicians must be counseled on surgical expectations preoperatively and made aware of the significantly higher risks involved when a DNR order exists in the setting of emergency surgical management of bowel obstruction.