Guidelines for perioperative do-not-resuscitate policies

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.

Beyond the Do-not-resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients

American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, "full code" is the default option irrespective of clinical circumstances and patient preferences. It is time to revisit this approach based on (1) increasing understanding of the power of default options in healthcare settings, (2) changing demographics and growing evidence suggesting that an expanding subset of patients is vulnerable to poor outcomes after perioperative cardiopulmonary resuscitation (CPR), and (3) recommendations from multiple societies promoting risk assessment and goal-concordant care in older surgical patients. The authors reconsider current guidelines in the context of these developments and advocate for an expanded approach to decision-making regarding CPR, which involves identifying high-risk elderly patients and eliciting their preferences regarding CPR irrespective of existing or presumed code status.

The Role of Anesthesiologists in Perioperative Limitation of Potentially Life-Sustaining Medical Treatments: A Narrative Review and Perspective

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.

The Ethics of Surgery at End of Life

The role of the anesthesiologist cannot be understated when it comes to ethical decision making, especially at end of life. To best serve patients within the limits of the law, anesthesiologists must arm themselves with an understanding of how the laws surrounding ethical decision-making impact daily practices. It is also important to know what rights and duties a patient or surrogate has in the decision-making process. With proper understanding of their responsibilities and the available tools, anesthesiologists can fulfill their roles as leaders and advocates for their patients as approaches to ethical decision-making at the end of life evolve.

Adult Perianesthesia Do Not Resuscitate Orders: A Systematic Review

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.

Do-Not-Resuscitate Status Is Associated With Increased Mortality But Not Morbidity

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."

Morbidity and mortality after emergency lower extremity embolectomy

OBJECTIVE

Emergency lower extremity embolectomy is a common vascular surgical procedure that has poorly defined outcomes. Our goal was to define the perioperative morbidity for emergency embolectomy and develop a risk prediction model for perioperative mortality.

METHODS

The American College of Surgeons National Surgical Quality Improvement database was queried to identify patients undergoing emergency unilateral and lower extremity embolectomy. Patients with previous critical limb ischemia, bilateral embolectomy, nonemergency indication, and those undergoing concurrent bypass were excluded. Patient characteristics and postoperative morbidity and mortality were analyzed. Multivariate analysis for predictors of mortality was performed, and from this, a risk prediction model was developed to identify preoperative predictors of mortality.

RESULTS

There were 1749 patients (47.9% male) who met the inclusion criteria. The average age was 68.2 ± 14.8 years. Iliofemoral-popliteal embolectomy was performed in 1231 patients (70.4%), popliteal-tibioperoneal embolectomy in 303 (17.3%), and at both levels in 215 (12.3%). Fasciotomies were performed concurrently with embolectomy in 308 patients (17.6%). The 30-day postoperative mortality was 13.9%. Postoperative complications included myocardial infarction or cardiac arrest (4.7%), pulmonary complications (16.0%), and wound complications (8.2%). The rate of return to the operating room ≤30 days was 25.7%. Hospital length of stay was 9.8 ± 11.5 days, and the 30-day readmission rate was 16.3%. A perioperative mortality risk prediction model based on factors identified in multivariate analysis included age >70 years, male gender, functional dependence, history of chronic obstructive pulmonary disease, congestive heart failure, recent myocardial infarction/angina, chronic renal insufficiency, and steroid use. The model showed good discrimination (C = 0.769; 95% confidence interval, 0733-0.806) and calibrated well.

CONCLUSIONS

Emergency lower extremity embolectomy has high morbidity, mortality, and resource utilization. These data provide a benchmark for this complex patient population and may assist in risk stratifying patients, allowing for improved informed consent and goals of care at the time of presentation.

The "do-not-resuscitate" order in palliative surgery: Ethical issues and a review on policy in Hong Kong

A do-not-resuscitate (DNR) order, or "advance directive," is commonly seen in the cases of palliative patients who express a wish to withhold specific resuscitative therapies in the event of a cardiac arrest. With recent technological advances, there are increasing numbers of palliative patients who undergo surgical interventions to treat their symptoms and discomfort. The decision to suspend DNR orders for palliative surgery is always a matter for debate. The present article describes a case and the ethical issues involved and gives some practical suggestions for those facing similar problems. We also review the latest DNR policy in Hong Kong.

Promoting perioperative advance care planning: a systematic review of advance care planning decision aids

This systematic review identifies possible decision aids that promote perioperative advance care planning (ACP) and synthesizes the available evidence regarding their use. Using PubMed, EMBASE, Cochrane, SCOPUS, Web of Science, CINAHL, PsycINFO and Sociological Abstracts, researchers identified and screened articles for eligibility. Data were abstracted and risk of bias assessed for included articles. Thirty-nine of 5327 articles satisfied the eligibility criteria. Primarily completed in outpatient ambulatory populations, studies evaluated a variety of ACP decision aids. None were evaluated in a perioperative population. Fifty unique outcomes were reported with no head-to-head comparisons conducted. Findings are likely generalizable to a perioperative population and can inform development of a perioperative ACP decision aid. Future studies should compare the effectiveness of ACP decision aids.

Perioperative morbidity and mortality of cardiothoracic surgery in patients with a do-not-resuscitate order

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.

Patient and doctor attitudes and beliefs concerning perioperative do not resuscitate orders: anesthesiologists' growing compliance with patient autonomy and self determination guidelines

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.

Physician perspectives and compliance with patient advance directives: the role external factors play on physician decision making

BACKGROUND

Following passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians' decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients' ability to comprehend complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored.

METHODS

Attendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents' perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test.

RESULTS

Three hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient's AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to "pass away in peace." Few (17%) would forgo an AD following a family's request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician's decision as to whether to comply with a patient's AD.

CONCLUSIONS

Our findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient's initial wishes and preferences expressed by the AD.

Pre-existing do-not-resuscitate orders are not associated with increased postoperative morbidity at 30 days in surgical patients

OBJECTIVE

To assess the relationship between pre-existing do-not-resuscitate orders and the incidence of postoperative 30-day minor morbidity in surgical patients.

DESIGN

Retrospective analysis of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database in patients undergoing general surgical procedures between 2005 and 2008.

SETTING

All U.S. hospitals that participated in the American College of Surgeons National Surgical Quality Improvement Program, which is the nationally validated, risk-adjusted, outcomes-based program that uses a prospective, peer-controlled, validated database to quantify 30-day risk-adjusted surgical outcomes, allowing valid comparison of outcomes among all hospitals in the program.

INTERVENTIONS

American College of Surgeons National Surgical Quality Improvement Program data included preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both the inpatient and outpatient setting. The data were collected, validated, and submitted by a trained Surgical Clinical Reviewer at each site. Association between do-not-resuscitate status and minor and major morbidities was assessed using proportional hazards models adjusting for death as a competing risk.

MEASUREMENTS AND MAIN RESULTS

Of 635,265 patients in the database, 576,745 patients were analyzed. Propensity-matched analysis successfully matched 2,199 (of 2,687 [81.8%]) patients having pre-existing do-not-resuscitate orders (DNR group) with 6,002 non-do-not-resuscitate control subjects (nonDNR group). At any time point within 30 days of surgery, DNR patients were 16% (95% confidence interval, 3-28%; p = .02) less likely to have a minor complication as compared with nonDNR patients after accounting for the competing risk of death. DNR patients were more likely to experience 30-day mortality compared with nonDNR patients (hazard ratio, 2.3; 95% confidence interval, 1.9-2.7; p < .001). However, there was no association between pre-existing do-not-resuscitate orders and occurrence of any major complication (p = .65) treating death as a competing risk event. When associations between do-not-resuscitate orders and individual minor complications were analyzed, a pre-existing do-not-resuscitate order remained independently associated only with decreased odds of superficial surgical site infection (p = .001).

CONCLUSIONS

Undergoing surgery with a pre-existing do-not-resuscitate order did not increase the risk of having a postoperative minor or major morbidity at any time within the 30-day postoperative period. Results of health care in U.S. hospitals do not differ based on presence of do-not-resuscitate orders.

Should do-not-resuscitate orders be suspended for surgical cases?

PURPOSE OF REVIEW

There are significant misunderstandings about the management of perioperative do-not-resuscitate orders. This paper reviews some of the difficulties generated by the halting acceptance and inconsistent implementation of an ethically appropriate perioperative do-not-resuscitate policy that mandates reconsideration of existing do-not-resuscitate orders. It also offers strategies for empowerment of such a policy.

RECENT FINDINGS

Recent advances in the ethical practice of anesthesiology have centered on determining and correcting why perioperative do-not-resuscitate policies are poorly accepted, and how to establish a hospital-wide adherence to such policies. Barriers to ethically appropriate application of perioperative do-not-resuscitate orders include differing values and misunderstandings between physicians and their patients - and also between anesthesiologists and other physicians - as well as medicolegal concerns. Policies should be designed and implemented at the level of the healthcare institution, and they must be sufficiently flexible to permit the tailoring of the perioperative do-not-resuscitate order to the autonomous choice of the patient. Such policies should state unambiguously that existing do-not-resuscitate orders are to be reevaluated, delineate responsibilities for reconsidering the do-not-resuscitate order, state available options, define necessary documentation, and list resources for help.

SUMMARY

A well written perioperative do-not-resuscitate policy is essential for surmounting obstacles to a well functioning perioperative do-not-resuscitate system.

Perioperative do-not-resuscitate orders--doing 'nothing' when 'something' can be done

Cardiopulmonary resuscitation (CPR) has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources. Despite the desire to respect patient autonomy, there are many reasons why withholding CPR may be complicated in the perioperative setting. This review outlines these factors in order to offer practical suggestions and to provoke discussion among perioperative care providers. Although originally described for witnessed intraoperative arrests, closed chest cardiac massage quickly became universal practice, and a legal imperative in many hospitals. Concerns were raised by both health care workers and patient groups; this eventually led to the creation of the do-not-resuscitate (DNR) order. However, legal precedents and ethical interpretations dictated that patients were expected to receive full resuscitation unless there was explicit documentation to the contrary. In short, CPR became the only medical intervention that required an order to prevent it from being performed. Before the 1990s, patients routinely had pre-existing DNR orders suspended during the perioperative period. Several articles criticized this widespread practice, and the policy of 'required reconsideration' was proposed. Despite this, many practical issues have hindered widespread observance of DNR orders for surgical patients, including concerns related to the DNR order itself and difficulties related to the nature of the operating room environment. This review outlines the origins of the DNR order, and how it currently affects the patient presenting for surgery with a pre-existing DNR order. There are many obstacles yet to overcome, but several practical strategies exist to aid health care workers and patients alike.