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. 2023 Dec:118:26-33.
doi: 10.1016/j.jocn.2023.10.006. Epub 2023 Oct 17.

Association of Do-Not-Resuscitate orders and in-hospital mortality among patients undergoing cranial neurosurgery

Lan Zhang  1 , George P Albert  1 , Thomas A Pieters  2 , Daryl C McHugh  1 , Anthony O Asemota  3 , Debra E Roberts  1 , David Y Hwang  4 , Matthew T Bender  1 , Benjamin P George  5
Affiliations

Association of Do-Not-Resuscitate orders and in-hospital mortality among patients undergoing cranial neurosurgery

Lan Zhang et al. J Clin Neurosci. 2023 Dec.

Abstract

Background: Previous studies identified pre-existing DNR orders as a predictor of mortality after surgery. We sought to evaluate mortality of patients receiving cranial neurosurgery with DNR orders placed at the time of, or within 24 h of admission.

Methods: We performed a retrospective cohort study using the California State Inpatient Database, January 2018 to December 2020. We used International Classification of Diseases, 10th Revision (ICD-10) codes to identify emergent hospitalizations with principal diagnosis of brain injury, including traumatic brain injury [TBI], ischemic stroke [IS], intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH], or malignant brain tumor [mBT]. We used procedure and Diagnosis Related Group codes to identify cranial neurosurgery. Patients with DNR were one-to-one matched to non-DNR controls based on diagnosis (exact matching), age, sex, Elixhauser comorbidity index, and organ failure (coarsened matching). The primary outcome was inpatient mortality.

Results: In California, 30,384 patients underwent cranial neurosurgery, 2018-2020 (n = 3,112, 10% DNR). DNR patients were older, more often female, more often White, with greater comorbidity and organ system dysfunction. There were 2,505 patients with DNR orders 1:1 matched to controls. Patients with DNR had greater inpatient mortality (56% vs. 23%, p < 0.001; Hazard Ratio 3.11, 95% CI 2.50-3.86), received tracheostomy (Odds Ratio [OR] 0.37, 95% CI 0.24-0.57) and gastrostomy less (OR 0.48, 95% CI 0.39-0.58) compared to controls. Multivariable analysis of the unmatched cohort demonstrated similar results.

Conclusion: Patients undergoing cranial neurosurgery with early or pre-existing DNR have high inpatient mortality compared to clinically similar non-DNR patients; 1 in 2 died during their hospitalization.

Keywords: Advance directives; Brain injury; Cranial neurosurgery; Do-Not-Resuscitate; Mortality; Outcomes; Stroke.

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Conflict of interest statement

Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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