The Role of Palliative Care in New Perioperative DNR Orders: Risk Factors and Timing

TL;DR

This study explores how palliative care consultations relate to new DNR orders in older surgical patients, finding that they often occur on the same day and close to death.

Contribution

The study identifies the timing and association between palliative care consultations and new DNR orders in older surgical patients.

Findings

45% of patients with new DNR orders and palliative care consultations had both on the same day.

57% of palliative care consultations occurred within one day prior to death.

Palliative care was significantly associated with new DNR orders (OR 9.95).

Abstract

As the population ages, there is an increased need for comprehensive goals of care (GOC) discussions which often include Do-Not-Resuscitate (DNR) orders. DNR orders are being increasingly studied, but it remains unknown how palliative care consultation (PCC) relates in older adult surgical patients. The American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Verification pilot program data was utilized from January 1, 2015 to December 31, 2019. The primary outcome was new DNR order within 30 days of primary operation for patients 65 and older. The association between PCC and DNR was assessed including timing. There were 44,172 patients, 2.7% of which had a new DNR order. 21% were placed preoperatively, 33% the day of surgery, 46% postoperatively. Of the patients who had DNR orders placed, 32% had PCCs versus 0.5% of those who did not have DNR orders (p < 0.0001). 45% of patients with both new DNR and PCC had them placed on the same day, 10% of PCC were before new DNR, and 45% were after. 57% of PCCs were placed ≤1 day prior to death and 49% of PCCs were placed >7 and ≤30 days postoperatively. After adjustment, PCC was significantly associated with new DNR (OR 9.95; 95% CI 6.42-15.42). Almost half of PCC and new DNR orders occur on the same day. Half of PCCs are on the same day as death signifying need for earlier GOC discussions. Further research is needed to better identify risk factors for earlier PCC to inform GOC.