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Invited Critique |

Surgery and Do-Not-Resuscitate Orders: The Real Risks Defined:  Comment on “High Mortality in Surgical Patients With Do-Not-Resuscitate Orders”

Kelly L. McCoy, MD; Sally E. Carty, MD
Arch Surg. 2011;146(8):928-929. doi:10.1001/archsurg.2011.177.
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Some of the most unpleasant yet memorable conversations we have as surgeons include those conducted in the wee hours of the night with patients facing terminal illness plus an acute surgical emergency. Often we experience the all-too-familiar ethical squeeze play—why am I the one to conduct this sad, wrenching conversation when the patient has already chosen to let death take its course?

Controversy over perioperative management of DNR orders has been widely recounted, culminating in the position of “required reconsideration” by esteemed groups including the American College of Surgeons and the American Society of Anesthesiologists.1,2 Detailed outcome data for DNR patients who choose surgery have thus far been sparse. Through in-depth interviews, Clemency and Thompson3 found that 83% of patients queried consider surgery despite a preexisting DNR order, while Wenger et al4 showed increased mortality among hospitalized medical patients with a DNR order. In this coherent and very large study based on age- and procedure-matched NSQIP data, Kazaure et al5 now demonstrate similar findings for an exclusively surgical population. They also show that most DNR operations are both nonemergent and major, with a high short-term mortality rate of 17% that is triple the rate for non-DNR patients. They also found that a recent decline in functional status occurs more often in DNR patients, underlining the common involvement of family members in surgical decision making.

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