Division of Surgical Oncology, Department of Surgery, Duke University, Durham, North Carolina, USA.
Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA.
J Am Geriatr Soc. 2021 Dec;69(12):3445-3456. doi: 10.1111/jgs.17391. Epub 2021 Jul 31.
There is a paucity of data on older adults (age ≥65 years) undergoing surgery who had an inpatient do-not-resuscitate (DNR) order, and the association between timing of DNR order and outcomes.
This was a retrospective analysis of 1976 older adults in the American College of Surgeons National Surgical Quality Improvement Program geriatric-specific database (2014-2018). Patients were stratified by institution of a DNR order during their surgical admission ("new-DNR" vs. "no-DNR"), and matched by age (±3 years), frailty score (range: 0-1), and procedure. The main outcome of interest was occurrence of death or hospice transition (DoH) ≤30 postoperative days; this was analyzed using bivariate and multivariable methods.
One in 36 older adults had a new-DNR order. After matching, there were 988 new-DNR and 988 no-DNR patients. Median age and frailty score were 82 years and 0.2, respectively. Most underwent orthopedic (47.6%), general (37.6%), and vascular procedures (8.4%). Overall DoH rate ≤30 days was 44.4% for new-DNR versus 4.0% for no-DNR patients (p < 0.001). DoH rate for patients who had DNR orders placed in the preoperative, day of surgery, and postoperative setting was 16.7%, 23.3%, and 64.6%, respectively (p < 0.001). In multivariable analysis, compared to no-DNR patients, those with a new-DNR order had a 28-fold higher adjusted odds of DoH (odds ratio [OR] 28.1, 95% confidence interval: 13.0-60.1, p < 0.001); however, odds were 10-fold lower if the DNR order was placed preoperatively (OR: 5.8, p = 0.003) versus postoperatively (OR: 52.9, p < 0.001). Traditional markers of poor postoperative outcomes such as American Society of Anesthesiologists class and emergency surgery were not independently associated with DoH.
An inpatient DNR order was associated with risk of DoH independent of traditional markers of poor surgical outcomes. Further research is needed to understand factors leading to a DNR order that may aid early recognition of high-risk older adults undergoing surgery.
关于在院期间下达了不可复苏（Do Not Resuscitate，DNR）医嘱的老年患者（年龄≥65 岁），以及 DNR 医嘱下达时间与结局之间的关联，相关数据较为匮乏。
这是一项回顾性分析，纳入了美国外科医师学会国家外科质量改进计划老年特定数据库（2014-2018 年）中的 1976 名老年患者。根据患者在外科住院期间下达 DNR 医嘱的时间（“新下达 DNR”与“无 DNR”）进行分层，并通过年龄（±3 岁）、衰弱评分（范围：0-1）和手术类型进行匹配。主要结局指标为术后 30 天内发生死亡或转入临终关怀（DoH）；采用双变量和多变量方法进行分析。
1/36 的老年患者下达了新的 DNR 医嘱。匹配后，新下达 DNR 组有 988 例，无 DNR 组有 988 例。中位年龄和衰弱评分为 82 岁和 0.2。大多数患者接受的是骨科（47.6%）、普外科（37.6%）和血管手术（8.4%）。新下达 DNR 组术后 30 天内 DoH 发生率为 44.4%，而无 DNR 组为 4.0%（p<0.001）。术前、手术当天和术后下达 DNR 医嘱的患者的 DoH 发生率分别为 16.7%、23.3%和 64.6%（p<0.001）。多变量分析显示，与无 DNR 组相比，新下达 DNR 组的调整后 DoH 比值比（odds ratio，OR）为 28.1（95%置信区间：13.0-60.1，p<0.001）；但如果 DNR 医嘱是在术前下达，OR 为 5.8（p=0.003），而如果是在术后下达，OR 为 52.9（p<0.001），则 OR 降低 10 倍。美国麻醉医师学会（American Society of Anesthesiologists，ASA）分级和急诊手术等传统不良术后结局标志物与 DoH 无独立相关性。
在院期间下达 DNR 医嘱与 DoH 风险相关，独立于传统的不良手术结局标志物。需要进一步研究导致下达 DNR 医嘱的因素，以便早期识别接受手术的高风险老年患者。
