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Devinney MJ, Treggiari MM. The role of Advance Directives and Living Wills in Anesthesia Practice. Anesthesiol Clin 2024; 42:377-392. [PMID: 39054014 DOI: 10.1016/j.anclin.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Preoperative review of existing advance directives and a discussion of patient goals should be routinely done to address any potential limitations on resuscitative therapies during perioperative care. Both surgeons and anesthesiologists should be collaboratively involved in these discussions, and all perioperative physicians should receive training in shared decision making and goals of care discussions. These discussions should center around patient preferences for limitations on life-sustaining medical therapy, which should be accurately documented and adhered to during the perioperative period. Patients should be informed that limitations of life-sustaining medical therapy may increase their risk of postoperative mortality.
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Affiliation(s)
- Michael J Devinney
- Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA; Department of Anesthesiology, Duke University School of Medicine, 40 Medicine Circle, Room 4317, Orange Zone, Duke Hospital South, Durham, NC 27710, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA; Department of Anesthesiology, Duke University School of Medicine, 3 Genome Court, MSRB-3, 6116, Durham, NC 27710, USA.
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2
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Do Not Attempt Resuscitation in the Operating Room: A Misconstrued Paradox? J Am Coll Surg 2022; 234:953-957. [DOI: 10.1097/xcs.0000000000000116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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3
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Cushman T, Waisel DB, Treggiari MM. The Role of Anesthesiologists in Perioperative Limitation of Potentially Life-Sustaining Medical Treatments: A Narrative Review and Perspective. Anesth Analg 2021; 133:663-675. [PMID: 34014183 DOI: 10.1213/ane.0000000000005559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
No patient arrives at the hospital to undergo general anesthesia for its own sake. Anesthesiology is a symbiont specialty, with the primary mission of preventing physical and psychological pain, easing anxiety, and shepherding physiologic homeostasis so that other care may safely progress. For most elective surgeries, the patient-anesthesiologist relationship begins shortly before and ends after the immediate perioperative period. While this may tempt anesthesiologists to defer goals of care discussions to our surgical or primary care colleagues, we have both an ethical and a practical imperative to share this responsibility. Since the early 1990s, the American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA), and the Association of Perioperative Registered Nurses (AORN) have mandated a "required reconsideration" of do-not-resuscitate (DNR) orders. Key ethical considerations and guiding principles informing this "required reconsideration" have been extensively discussed in the literature and include respect for patient autonomy, beneficence, and nonmaleficence. In this article, we address how well these principles and guidelines are translated into daily clinical practice and how often anesthesiologists actually discuss goals of care or potential limitations to life-sustaining medical treatments (LSMTs) before administering anesthesia or sedation. Having done so, we review how often providers implement goal-concordant care, that is, care that reflects and adheres to the stated patient wishes. We conclude with describing several key gaps in the literature on goal-concordance of perioperative care for patients with limitations on LSMT and summarize novel strategies and promising efforts described in recent literature to improve goal-concordance of perioperative care.
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Affiliation(s)
- Tera Cushman
- From the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - David B Waisel
- Department of Anesthesiology, Yale University, New Haven, Connecticut
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AORN
Position Statement on Perioperative Care of Patients With Do‐Not‐Resuscitate or Allow‐Natural‐Death Orders. AORN J 2020. [DOI: 10.1002/aorn.13183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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5
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Hardin J, Forshier B. Adult Perianesthesia Do Not Resuscitate Orders: A Systematic Review. J Perianesth Nurs 2019; 34:1054-1068.e18. [PMID: 31230930 DOI: 10.1016/j.jopan.2019.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/12/2019] [Accepted: 03/23/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this systematic review is to assess if Do Not Resuscitate (DNR) orders should be routinely rescinded during anesthesia, determine if consensus on retaining DNR orders exists in the literature, and explore the current state of clinical practice. DESIGN This systematic review followed preferred reporting items for systematic reviews and meta-analyses guidelines. METHODS In June 2018, the Cumulative Index to Nursing and Allied Health Literature and PubMed databases were systematically searched using defined inclusion/exclusion criteria. FINDINGS Ninety-one articles from the databases were pooled with 16 works identified as formative to the research questions. Forty-nine articles were analyzed and included in this study. CONCLUSIONS It is unethical to automatically rescind DNR orders during anesthesia. Patients have the right to retain their DNR orders unaltered or modify them for the perianesthesia period. Sufficient evidence exists to create meaningful policy at every level. A consensus exists among professional organizations that the standard of care is a required reconsideration of DNR orders before anesthesia.
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Brown SES, Antiel RM, Blinman TA, Shaw S, Neuman MD, Feudtner C. Pediatric Perioperative DNR Orders: A Case Series in a Children's Hospital. J Pain Symptom Manage 2019; 57:971-979. [PMID: 30731168 DOI: 10.1016/j.jpainsymman.2019.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 02/05/2023]
Abstract
CONTEXT Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period are limited. OBJECTIVES To evaluate perioperative management of DNR orders at a tertiary care children's hospital. METHODS We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from February 1, 2016, to August 1, 2017. Using standardized case report forms, we abstracted the following from physician notes: 1) patient/family wishes with respect to the DNR, 2) whether preoperative DNR orders were continued, modified, or suspended during the perioperative period, and 3) whether life-threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision-making in the perioperative period. RESULTS Twenty-three patients aged six days to 17 years had a DNR order in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures and suspended for 15 (51%). Three children (13%) suffered life-threatening events. We identified four time points in the perioperative period where systematic reconsideration should be documented in the medical record, and identified recommended personnel involved and important discussion points at each time point. CONCLUSION Opportunities exist to improve how DNR orders are managed during the perioperative period.
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Affiliation(s)
- Sydney E S Brown
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Ryan M Antiel
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Thane A Blinman
- Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susanna Shaw
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mark D Neuman
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Fallat ME, Hardy C, Meyers RL, Besner GE, Davidoff A, Heiss KF, Agarwal R, Tobias J, Brown RE, Guzzetta NA, Honkanen A, Landrigan-Ossar M, Katz AL, Laventhal NT, Macauley RC, Moon MR, Okun AL, Opel DJ, Statter MB. Interpretation of Do Not Attempt Resuscitation Orders for Children Requiring Anesthesia and Surgery. Pediatrics 2018; 141:peds.2018-0598. [PMID: 29686145 DOI: 10.1542/peds.2018-0598] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This clinical report addresses the topic of pre-existing do not attempt resuscitation or limited resuscitation orders for children and adolescents undergoing anesthesia and surgery. Pertinent considerations for the clinician include the rights of children, decision-making by parents or legally approved representatives, the process of informed consent, and the roles of surgeon and anesthesiologist. A process of re-evaluation of the do not attempt resuscitation orders, called "required reconsideration," should be incorporated into the process of informed consent for surgery and anesthesia, distinguishing between goal-directed and procedure-directed approaches. The child's individual needs are best served by allowing the parent or legally approved representative and involved clinicians to consider whether full resuscitation, limitations based on procedures, or limitations based on goals is most appropriate.
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Affiliation(s)
- Mary E. Fallat
- Department of Surgery, University of Louisville, Louisville, Kentucky; and
| | - Courtney Hardy
- Division of Pediatric Anesthesiology, Washington University in St Louis, St Louis, Missouri
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Walsh EC, Brovman EY, Bader AM, Urman RD. Do-Not-Resuscitate Status Is Associated With Increased Mortality But Not Morbidity. Anesth Analg 2017; 125:1484-1493. [PMID: 28319514 DOI: 10.1213/ane.0000000000001904] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Do-not-resuscitate (DNR) orders instruct medical personnel to forego cardiopulmonary resuscitation in the event of cardiopulmonary arrest, but they do not preclude surgical management. Several studies have reported that DNR status is an independent predictor of 30-day mortality; however, the etiology of increased mortality remains unclear. We hypothesized that DNR patients would demonstrate increased postoperative mortality, but not morbidity, relative to non-DNR patients undergoing the same procedures. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database for 2007-2013, we performed a retrospective analysis to compare DNR and non-DNR cohorts matched by the most common procedures performed in DNR patients. We employed univariable and multivariable logistic regression to characterize patterns of care in the perioperative period as well as identify independent risk factors for increased mortality and assess for the presence of "failure to rescue." RESULTS The most common procedures performed on DNR patients were emergent and centered on immediate symptom relief. When adjusting for preoperative factors, DNR patients were still found to have increased incidence of postoperative mortality (odds ratio 2.54 [2.29-2.82], P < .001) but not postoperative morbidity at 30 days. In addition, cardiopulmonary resuscitative measures and unplanned intubation were found to be less frequent in the DNR cohort. CONCLUSIONS These findings suggest that increased mortality is the result of adherence to goals of care rather than "failure to rescue."
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Affiliation(s)
- Elisa C Walsh
- From the Harvard Medical School, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Attri JP, Sandhu GK, Mohan B, Bala N, Sandhu KS, Bansal L. Conflicts in operating room: Focus on causes and resolution. Saudi J Anaesth 2015; 9:457-63. [PMID: 26543468 PMCID: PMC4610095 DOI: 10.4103/1658-354x.159476] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The operation theater (OT) environment is the most complex and volatile workplace where two coequal physicians share responsibility of one patient. Difference in information, opinion, values, experience and interests between a surgeon and anesthesiologist may arise while working in high-pressure environments like OT, which may trigger conflict. Quality of patient care depends on effective teamwork for which multidisciplinary communication is an essential part. Troubled relationships leads to conflicts and conflicts leads to stressful work environment which hinders the safe discharge of patient care. Unresolved conflicts can harm the relationship but when handled in a positive way it provides an opportunity for growth and ultimately strengthening the bond between two people. By learning the skills to resolve conflict, we can keep our professional relationship healthy and strong which is an important component of good patient care.
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Affiliation(s)
- Joginder Pal Attri
- Department of Anesthesia, Government Medical College, Amritsar, Punjab, India
| | | | - Brij Mohan
- Department of Anesthesia, Government Medical College, Amritsar, Punjab, India
| | - Neeru Bala
- Department of Psychiatry, Government Medical College, Amritsar, Punjab, India
| | | | - Lipsy Bansal
- Department of Anesthesia, Government Medical College, Amritsar, Punjab, India
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Sundararajan K, Flabouris A, Keeshan A, Cramey T. Documentation of limitation of medical therapy at the time of a rapid response team call. AUST HEALTH REV 2014; 38:218-22. [PMID: 24589293 DOI: 10.1071/ah13138] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 12/12/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aims of the present study were to: (1) describe the documentation process of limitation of medical therapy (LMT) orders at the time of a rapid response team (RRT) call; and (2) compare documented LMT orders not associated with an RRT call (control, Group 1) with LMT orders documented at the time of an RRT call (Group 2). METHODS A descriptive study, over a 6-month period (February-August 2011), involving the review of the medical records of patients prospectively identified as either Group 1 or Group 2. RESULTS There were 994 RRT calls; of these, 50 patients (5%) had an LMT order documented by the RRT. A cardiac arrest was the trigger for the RRT for six patients (12%). Patients in Group 1 (n=50) and Group 2 were of similar median age (80.5 vs 78.5 years; P=0.30), LMTs were recorded at a similar time of day (15:30 vs 15:55 hours; P=0.52) and day of the week (weekend: 32% vs 35%; P=0.72). Comparing group 2 with Group 1, the RRT was less likely to document a not-for-resuscitation (NFR; 31 (62%) vs 49 (98%); P<0.01) or a not-for-ICU (NFICU; 18 (36%) vs 41 (82%); P<0.01) order, but more likely to document a not-for-RRT call (NFRRT; 31 (62%) vs 22 (44%); P=0.04) and modified RRT calling criteria (MRRT; 4 (8%) vs 0 (0%); P=0.04) orders. For Group 2 compared with Group 1 orders, involvement of the patient in the decision making process (9 (18%) vs 25 (50%); P<0.01) or the next of kin (29 (58%) vs 45 (90%); P<0.01) was documented less often. CONCLUSIONS Documentation of LMT orders at the time of an RRT call is less likely to include documented involvement of patients or their next of kin, and is more likely to be an NFRRT or MRRT order. These findings have implications for overall clinical governance. What is known about the topic? RRT are not infrequently involved in documenting LMT orders. What does this paper add? This is the first study in Australasia to look into the timing and circumstances surrounding the issuing of a NFR order during an RRT call. The study findings clarify the type of LMT orders documented by RRT and to what extent patients, their carers and senior medical staff are involved. What are the implications for practitioners? Our findings indicate that, in the setting of a rapid response system, there is a need to consider beyond the narrow interpretation of the NFR order, when a NFRRT may also be appropriate. This will require standardisation of such nomenclature, and training and education of those involved in documenting and interpreting such orders. Equally, it will require a different approach to the discussion with patients and their carers as to what the implications of an NFRRT order are. The findings also have significant implications as to the senior medical oversight of LMT, in particular for RRT, for whom it is their first encounter with such patients. Finally, the findings suggest that consideration be given to better delineating the documentation of the role of nursing staff when setting LMT orders.
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Affiliation(s)
- K Sundararajan
- Intensive Care Unit, Critical Care Services, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - A Flabouris
- Intensive Care Unit, Critical Care Services, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - Alexander Keeshan
- Intensive Care Unit, Critical Care Services, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - Tracey Cramey
- Intensive Care Unit, Critical Care Services, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
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Herreros B, Ramnath VR, Bishop L, Pintor E, Martín MD, Sánchez-González MA. Clinical ethics protocols in the clinical ethics committees of Madrid. JOURNAL OF MEDICAL ETHICS 2014; 40:205-208. [PMID: 23579231 DOI: 10.1136/medethics-2012-100791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Currently, The nature and scope of Clinical Ethics Protocols (CEPs) in Madrid (Spain) are not well understood. OBJECTIVES The main objective is to describe the features of 'guideline/recommendation' type CEPs that have been or are being developed by existing Clinical Ethics Committees (CECs) in Madrid. Secondary objectives include characterisation of those CECs that have been the most prolific in reference to CEP creation and implementation and identification of any trends in future CEP development. METHODS We collected CEPs produced and in process by CECs accredited in the public hospitals in Madrid, Spain, from 1996 to 2008. RESULTS CECs developed 30 CEPs, with 10 more in process. The most common topic is refusal of treatment (seven CEPs developed; two in process). If CEPs addressing terminal illness, Do-Not-Resuscitate orders and advance directives are placed into a separate 'ethical problems at the end of life' category, this CEP subject emerges as the most common (eight developed; four in process). There is a relationship between the age of the CEC and the development of CEPs (the oldest CECs have developed more CEPs). CECs now seem to be more likely to engage in CEP development. CONCLUSIONS The CECs in Madrid, Spain, have developed a significant number of CEPs (30 in total and 10 in process) and there is a trend towards continued development. The most frequent topics are ethical problems at the end of life and refusal of treatment by the patient.
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Affiliation(s)
- Benjamin Herreros
- Department of Biomedical Sciences, European University of Madrid, , Villaviciosa de Odon, Madrid, Spain
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12
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Maxwell BG, Lobato RL, Cason MB, Wong JK. Perioperative morbidity and mortality of cardiothoracic surgery in patients with a do-not-resuscitate order. PeerJ 2014; 2:e245. [PMID: 24498575 PMCID: PMC3912447 DOI: 10.7717/peerj.245] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 12/21/2013] [Indexed: 12/21/2022] Open
Abstract
Background. Do-not-resuscitate (DNR) orders are often active in patients with multiple comorbidities and a short natural life expectancy, but limited information exists as to how often these patients undergo high-risk operations and of the perioperative outcomes in this population. Methods. Using comprehensive inpatient administrative data from the Public Discharge Data file (years 2005 through 2010) of the California Office of Statewide Health Planning and Development, which includes a dedicated variable recording DNR status, we identified cohorts of DNR patients who underwent major cardiac or thoracic operations and compared themto age- and procedure-matched comparison cohorts. The primary study outcome was in-hospital mortality. Results. DNR status was not uncommon in cardiac (n = 2,678, 1.1% of all admissions for cardiac surgery, age 71.6 ± 15.9 years) and thoracic (n = 3,129, 3.7% of all admissions for thoracic surgery, age 73.8 ± 13.6 years) surgical patient populations. Relative to controls, patients who were DNR experienced significantly greater inhospital mortality after cardiac (37.5% vs. 11.2%, p < 0.0001 and thoracic (25.4% vs. 6.4%) operations. DNR status remained an independent predictor of in-hospital mortality onmultivariate analysis after adjustment for baseline and comorbid conditions in both the cardiac (OR 4.78, 95% confidence interval 4.21–5.41, p < 0.0001) and thoracic (OR 6.11, 95% confidence interval 5.37–6.94, p < 0.0001) cohorts. Conclusions. DNR status is associated with worse outcomes of cardiothoracic surgery even when controlling for age, race, insurance status, and serious comorbid disease. DNR status appears to be a marker of substantial perioperative risk, and may warrant substantial consideration when framing discussions of surgical risk and benefit, resource utilization, and biomedical ethics surrounding end-of-life care.
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Affiliation(s)
- Bryan G Maxwell
- Department of Anesthesiology and Critical Care Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Robert L Lobato
- Department of Anesthesia , Cedars-Sinai Medical Center , Los Angeles, CA , USA
| | - Molly B Cason
- Department of Anesthesiology and Critical Care Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Jim K Wong
- Department of Anesthesia , Stanford University School of Medicine , Stanford, CA , USA
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Burkle CM, Swetz KM, Armstrong MH, Keegan MT. Patient and doctor attitudes and beliefs concerning perioperative do not resuscitate orders: anesthesiologists' growing compliance with patient autonomy and self determination guidelines. BMC Anesthesiol 2013; 13:2. [PMID: 23320623 PMCID: PMC3548687 DOI: 10.1186/1471-2253-13-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 11/23/2012] [Indexed: 12/21/2022] Open
Abstract
UNLABELLED BACKGROUND In 1993, the American Society of Anesthesiologists (ASA) published guidelines stating that automatic perioperative suspension of Do Not Resuscitate (DNR) orders conflicts with patients' rights to self-determination. Almost 20 years later, we aimed to explore both patient and doctor views concerning perioperative DNR status. METHODS Five-hundred consecutive patients visiting our preoperative evaluation clinic were surveyed and asked whether they had made decisions regarding resuscitation and to rate their agreement with several statements concerning perioperative resuscitation. Anesthesiologists, surgeons and internists at our tertiary referral institution were also surveyed. They were asked to assess their likelihood of following a hypothetical patient's DNR status and to rate their level of agreement with a series of non-scenario related statements concerning ethical and practical aspects of perioperative resuscitation. RESULTS Over half of patients (57%) agreed that pre-existing DNR requests should be suspended while undergoing a surgical procedure under anesthesia, but 92% believed a discussion between the doctor and patient regarding perioperative resuscitation plans should still occur. Thirty percent of doctors completing the survey believed that DNR orders should automatically be suspended intraoperatively. Anesthesiologists (18%) were significantly less likely to suspend DNR orders than surgeons (38%) or internists (34%) (p < 0.01). CONCLUSIONS Although many patients agree that their DNR orders should be suspended for their operation, they expect a discussion regarding the performance and nature of perioperative resuscitation. In contrast to previous studies, anesthesiologists were least likely to automatically suspend a DNR order.
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Affiliation(s)
- Christopher M Burkle
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Keith M Swetz
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Matthew H Armstrong
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Mark T Keegan
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
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14
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Lamba S, Murphy P, McVicker S, Harris Smith J, Mosenthal AC. Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage 2012; 44:508-19. [PMID: 22765967 DOI: 10.1016/j.jpainsymman.2011.10.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/09/2011] [Accepted: 10/12/2011] [Indexed: 11/24/2022]
Abstract
CONTEXT Patients, families, and surgeons often have high expectations of life-saving surgery following liver transplantation (LT), despite the presence of a severe life-limiting underlying illness. Hence, transition from curative to palliative care is difficult and may create conflicts around goals of care. OBJECTIVES We hypothesized that early communication with physicians/families would improve end-of-life care practice in the LT service patients. METHODS Prospective, observational, pre/poststudy of consecutive LT service, surgical intensive care unit (SICU) patients, before and after a palliative care intervention was integrated. This included Part I (at admission), family support, prognosis, and patient preferences delineation; and Part II (within 72 hours), interdisciplinary family meeting. Data on goals-of-care discussions, do-not-resuscitate (DNR) orders, withdrawal of life support, and family perceptions were collected. RESULTS Seventy-nine LT patients with 21 deaths comprised the baseline group and 104 patients with 31 deaths the intervention group. Eighty-five percent of patients received Part I and 58% Part II of the intervention. Goals-of-care discussions on physician rounds increased from 2% to 38% of patient-days. During the intervention, although mortality rates were unchanged, DNR status increased (52-81%); withdrawal of life support increased (35-68%); DNR was instituted earlier; admission to DNR decreased (mean of 38-19 days); DNR to death time increased (two to four days); and SICU mean length of stay decreased (by three days). Family responses suggested more "time with family"/"time to say goodbye." CONCLUSION Interdisciplinary communication interventions with physicians and families resulted in earlier consensus around goals of care for dying LT patients. Early integration of palliative care alongside disease-directed curative care can be accomplished in the SICU without change in mortality and has the ability to improve end-of-life care practice in LT patients.
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Affiliation(s)
- Sangeeta Lamba
- New Jersey Medical School, University of Medicine and Dentistry of New Jersey, University Hospital, Newark, NJ 07103, USA
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