Perioperative Do‐Not‐Resuscitate Suspension: The Patient's Perspective

Directives Limiting Care in the Perianesthesia Setting: A Foucauldian Case Study Report

PURPOSE

The purpose of this inquiry is to explore how adult patients with limiting directives, their families, and clinicians make decisions about resuscitative status during anesthesia. Although current practice guidelines recommend mandatory reconsideration of do not resuscitate and other limiting directives before anesthesia, the automatic suspension of directives limiting care continues in the adult perianesthesia setting. How patients and clinicians talk about these limiting directives is underexplored in the literature.

DESIGN

This qualitative inquiry used the Foucauldian Poststructural Case Study Design.

METHODS

Data were collected through interviews and observation of patients with existing advance directives who underwent surgery, family members, and perianesthesia clinicians who participated in their care. Contextualizing analysis, a qualitative methodology that fits well with Foucauldian Poststructural Case Study Design, was used to rigorously examine the data.

FINDINGS

Twenty-seven participants completed the observation and interview components of the study. Observation data were collected from an additional 18 participants. Four authoritative discourses that constructed choices available to patients and clinicians were identified. The "We'll just suspend" discourse permeates perianesthesia culture and produces a will to suspend the limiting directive among clinicians. Discourses about lack of time, a desire not to talk about advance directives unless it is essential to care, and confusion about who is responsible for addressing the limiting directive were also identified in the case. In addition, patients had difficulty translating advance directive choices into the perianesthesia context, and this difficulty may be misunderstood by clinicians as agreement with the plan of care. Finally, power networks may sequester knowledge about patients' choices, leading to tension among clinicians and creating barriers to honoring patients' advance directive choices.

CONCLUSIONS

Results suggest that even where policies of mandatory advance directive reconsideration exist, patients may experience environments that constrain their choices and decision-making agency.

Preoperative optimization of patients undergoing interventional procedures: infrastructure, logistics, and evidence-based medicine

PURPOSE OF REVIEW

Patients presenting for non-operating room procedures are often 'too sick' for surgery and require specific anesthesia care in remote areas with logistical and scheduling challenges.

RECENT FINDINGS

Increased complexity and scope of minimally invasive procedures have expanded this practice. In addition, the concept of therapeutic options other than conventional surgery is gaining traction.

SUMMARY

Our review of recent literature confirms the complexity and supports the safety of providing care in non-operating room anesthesia locations. Standard preanesthesia assessments and principles apply to these areas.

Perioperative Code Status Discussions: How Are We Doing?

Approximately 15% of patients with a code status of do-not-resuscitate (DNR) or do-not-intubate (DNI) present for surgery. Despite professional guidelines requiring discussions with patients regarding perioperative resuscitation, it is unclear whether these recommendations are consistently followed. Our review of 158 patient encounters with established DNR/DNI code status found that code status discussions (CSDs) were documented only 70% of the time, and code status orders were inconsistently entered to reflect those discussions. We present solutions to improve CSD documentation, including refining perioperative workflows, simplifying code status choices, optimizing electronic health record order entry, and a supplementary consent form to facilitate code status review.