'Do Not Attempt Resuscitation' (DNAR) decisions in patients with femoral fractures: modification, clinical management and outcome

BACKGROUND: increased provision of orthogeriatric expertise for patients with femoral fractures has led to implementation of 'Do Not Attempt Resuscitation' (DNAR) decisions prior to anaesthesia and surgery for fixation of their fractures. Review and modification of the DNAR decision by the medical team is necessary before surgery and is recommended by guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the General Medical Council. METHODS: over a 17-month period, DNAR decisions were already present or were implemented for the first time in 22 patients prior to scheduled surgical fixation of their femoral fractures. Data were collected prospectively on each patient's management, including modification of their DNAR decision, and outcome at 30 days and 1 year. RESULTS: two patients died prior to surgery. In eight of the 20 patients who underwent surgical fixation, there was no documentation regarding the status of the DNAR decision in the perioperative period. The 30-day mortality rate for those undergoing surgery was 15% (3/20). At 1 year, eight patients survived with six living in their own homes. CONCLUSIONS: despite the favourable outcomes for hip fracture patients with pre-existing DNAR decisions, this audit showed inadequate review and documentation of the DNAR decision in advance of surgery.