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
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
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.