Early postoperative death in extreme-risk patients: A perspective on surgical futility.

Abstract

Surgical futility is poorly defined. However, there are patients with extremely high preoperative risk who still undergo surgery and ultimately die, suggesting futile care. To further explore surgical futility, we examined the incidence and factors associated with extreme-risk patients undergoing major emergency general surgery with early death. The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all adults undergoing colectomy, small bowel resection, control of bleeding ulcer, lysis of adhesion, and exploratory laparotomy between 2007 and 2015. Extreme-risk was defined as having an estimated mortality risk ≥75% using the National Surgical Quality Improvement Program mortality-risk calculator. Futile care was defined as extreme-risk patients who died within 48 hours of an operation. The incidence of, and clinical factors associated with, futile surgery were identified. Of 94,350 emergency general surgery patients, 1.9% were extreme-risk. Among extreme-risk patients, 30-day mortality was 71.2%; 31.6% of extreme-risk patients died within 48 hours, representing futile care. Only 5.5% of extreme-risk patients were discharged home. Patients who were >80 years (odds ratio [OR] 6.25 vs 40-64; 95% confidence interval [CI], 4.51-8.66), septic (OR 4.63; 95% CI, 3.38-6.34), or had a dependent functional status (OR 2.50 vs independent; 95% CI, 1.83-3.43]) had higher odds of having a futile operation. A significant number of emergency general surgery operations were on extreme-risk patients who suffered early death, which may indicate futile care. Surgeons face numerous conflicting pressures when asked to perform potentially futile surgery. Additional research in the decision-making process in these cases is needed to understand why surgeons operate in such dire circumstances and whether they should.