Anesthesiologist Management of Perioperative Do-Not-Resuscitate Orders: A Simulation-Based Experiment

End of Life: What Is the Anesthesiologist's Role?

Anesthesiologists receive extensive training in the area of perioperative care and the specialized skills required to maintain life during surgery and complex procedures. Integrated into almost every facet of contemporary medicine, they interact with patients at multiple stages of their health care journeys. While traditionally thought of as the doctors best equipped to save lives, they may also be some of the best doctors to help navigate the chapters at the end of life. Successfully navigating end-of-life care, particularly in the COVID-19 era, is a complicated task. Competing ethical principles of autonomy and nonmaleficence may often be encountered as sophisticated medical technologies offer the promise of extending life longer than ever before seen. From encouraging patients to actively engage in advance care planning, normalizing the conversations around the end of life, employing our skills to relieve pain and suffering associated with dying, and using our empathy and communication skills to also care for the families of dying patients, there are many ways for the anesthesiologist to elevate the care provided at the end of life. The aim of this article is to review the existing literature on the role of the anesthesiologist in end-of-life care, as well as to encourage future development of our specialty in this area.

Efficacy of an Online Curriculum for Perioperative Goals of Care and Code Status Discussions: A Randomized Controlled Trial

BACKGROUND

Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature.

METHODS

In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa.

RESULTS

Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group.

CONCLUSIONS

Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

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.

Perioperative do-not-resuscitate orders: Trainee experiential learning in preserving patient autonomy and knowledge of professional guidelines

Anesthesiologists and surgeons have demonstrated a lack of familiarity with professional guidelines when providing care for surgical patients with a do-not-resuscitate (DNR) order. This substantially infringes on patient's self-autonomy; therefore, leading to substandard care particularly for palliative surgical procedures. The interventional nature of surgical procedures may create a different mentality of surgical "buy-in," that may unintentionally prioritize survivability over maintaining patient self-autonomy. While previous literature has demonstrated gains in communication skills with simulation training, no specific educational curriculum has been proposed to specifically address perioperative code status discussions. We designed a simulated standardized patient actor (SPA) encounter at the beginning of post-graduate year (PGY) 2, corresponding to the initiation of anesthesiology specific training, allowing residents to focus on the perioperative discussion in relation to the SPA's DNR order.Forty four anesthesiology residents volunteered to participate in the study. PGY-2 group (n = 17) completed an immediate post-intervention assessment, while PGY-3 group (n = 13) completed the assessment approximately 1 year after the educational initiative to ascertain retention. PGY-4 residents (n = 14) did not undergo any specific educational intervention on the topic, but were given the same assessment. The assessment consisted of an anonymized survey that examined familiarity with professional guidelines and hospital policies in relation to perioperative DNR orders. Subsequently, survey responses were compared between classes.Study participants that had not participated in the educational intervention reported a lack of prior formalized instruction on caring for intraoperative DNR patients. Second and third year residents outperformed senior residents in being aware of the professional guidelines that detail perioperative code status decision-making (47%, 62% vs 21%, P = .004). PGY-3 residents outperformed PGY-4 residents in correctly identifying a commonly held misconception that institutional policies allow for automatic perioperative DNR suspensions (85% vs 43%; P = .02). Residents from the PGY-3 class, who were 1 year removed the educational intervention while gaining 1 additional year of clinical anesthesiology training, consistently outperformed more senior residents who never received the intervention.Our training model for code-status training with anesthesiology residents showed significant gains. The best results were achieved when combining clinical experience with focused educational training.

Management of Do Not Resuscitate Orders Before Invasive Procedures

Background

In 2017, the US Department of Veterans Affairs (VA) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI), which created a portable and durable code status for use across its health care system. Patients who now have a durable do not resuscitate (DNR) status may undergo invasive procedures. Few studies have examined whether proceduralists discuss DNR status and document changes before procedures.

Objective

To assess baseline percentage of suspension of DNR before nonsurgical invasive procedures and determine whether an academic detailing intervention consisting of training proceduralists in the use of a template that allows rapid suspension of DNR status increases percentage of DNR acknowledgments.

Methods

Single-center, quasi-experimental pre- and postassessments were done in high-volume, procedural areas, including gastroenterology, cardiology, and interventional radiology, in a VA medical center. The primary outcome was the proceduralists' documentation of DNR status acknowledgment before a nonsurgical invasive procedure at baseline and after the intervention. Logistic regression was used to compare percentage of DNR acknowledgment with time (before, after) and procedural area and assessing their interaction in the model.

Results

The interaction between department and time revealed wide variation in documentation of DNR acknowledgment. Examining the model predicted percentages from the interaction, preintervention percentages for gastroenterology, cardiology and interventional radiology were 46%, 75.6%, and 7.5%, respectively, and postintervention model predicted percentages were 53.5%, 91.7%, and 26.3%, respectively. Only the before vs after contrast for interventional radiology was significantly different. When all procedural areas were combined, the percentage of DNR acknowledgment significantly improved from 38.6% to 61.1% (P = .01).

Conclusions

Before nonsurgical invasive procedures, the percentage of DNR acknowledgment was low but after, the intervention significantly improved. Further research is needed to assess its impact on patient-centered outcomes.

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.

Training Surgeons and Anesthesiologists to Facilitate End-of-Life Conversations With Patients and Families: A Systematic Review of Existing Educational Models

OBJECTIVE

Despite caring for patients near the end-of-life (EOL), surgeons and anesthesiologists report low confidence in their ability to facilitate EOL conversations. This discrepancy exists despite competency requirements and professional medical society recommendations. The objective of this systematic review is to identify articles describing EOL communication training available to surgeons and anesthesiologists, and to assess their methodological rigor to inform future curricular design and evaluation.

METHODS

This PRISMA-concordant systematic review identified English-language articles from PubMed, EMBASE, and manual review. Eligible articles included viewpoint pieces, and observational, qualitative, or case studies that featured an educational intervention for surgeons or anesthesiologists on EOL communication skills. Data on the study objective, setting, design, participants, intervention, and results were extracted and analyzed. The Newcastle-Ottawa Scale was used to assess methodological quality.

RESULTS

Database and manual search returned 2710 articles. A total of 2268 studies were screened by title and abstract, 46 reviewed in full-text, and 16 included in the final analysis. Fifteen studies were conducted exclusively in academic hospitals. Two studies included attending surgeons as participants; all others featured residents, fellows, or a mix thereof. Fifteen studies used simulated role-playing to teach and assess EOL communication skills. Measured outcomes included knowledge, attitudes, confidence, self-rated or observer-rated communication skills, and curriculum feedback; significance of results varied widely. Most studies lacked adequate methodological quality and appropriate control groups to be confident about the significance and applicability of their results.

CONCLUSIONS

There are few quality studies evaluating EOL communication training for surgeons and anesthesiologists. These programs frequently use role-playing to teach and assess EOL communication skills. More studies are needed to evaluate the effect of these interventions on patient outcomes. However, evaluating the effectiveness of these initiatives poses methodological challenges.

End-of-life discussions: Who's doing the talking?

PURPOSE

To determine, in a tertiary academic medical center, the reported frequency of end-of-life discussions among nurses and the influence of demographic factors on these discussions.

METHODS

Survey of nurses on frequency of end-of-life discussions in two urban academic medical centers. Chi-square tests were used to separately assess the relationship between age, gender, specialty, and experience with responses to the question, "Do you regularly talk with your patients about end-of-life wishes?"

RESULTS

Overall, more than one-third of respondents reported rarely or never discussing end-of-life wishes with their patients. Only specialty expertise (p<0.001) was statistically significantly associated with discussing end-of-life issues with patients. Over half of nurses specializing in critical care responded that they have these discussion "always" or "most of the time." However, for the specialties of surgery (59%) and anesthesiology (56%), the majority of respondents reported rarely or never having end-of-life discussions with patients.

CONCLUSIONS

In a survey conducted in two tertiary care institutions, more than one-third of nurses from all disciplines responded that they never or almost never discuss end-of-life issues with their patients. Specialty influenced the likelihood of discussing end-of-life issues with patients.

An Agenda for Improving Perioperative Code Status Discussion

Code status discussions (CSDs) clarify patient preferences for cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. CSDs are a key component of perioperative care, particularly at the end of life, and must be both patient-centered and shared. Physicians at all levels of training are insufficiently trained in and inappropriately perform CSD; this may be particularly true of perioperative physicians. In this article, we describe the difficulty of achieving a patient-centered, shared perioperative CSD in the case of a medical professional with a do-not-resuscitate order. We provide a brief background in cardiopulmonary resuscitation, do-not-resuscitate, and CSD before proposing an agenda for improving perioperative CSD.

Advance Directives and Operating: Room for Improvement?

Anesthesiologists and surgeons are frequently called on to perform procedures on critically ill patients with advanced directives. We assessed the attitudes of attending and resident surgeons and anesthesiologists at our institution regarding their understanding of and practice around the application of consenting critically ill patients with advance directives in the operating room. To do so, we deployed a survey after interdepartmental grand rounds, featuring a panel discussion of ethically complex cases featuring end-of-life issues.

Do Not Resuscitate, Anesthesia, and Perioperative Care: A Not So Clear Order

BACKGROUND

Advance directives guide healthcare providers to listen to and respect patients' wishes regarding their right to die in circumstances when cardiopulmonary resuscitation is required, and hospitals accredited by The Joint Commission are required to have a do-not-resuscitate (DNR) policy in place. However, when surgery and anesthesia are necessary for the care of the patient with a DNR order, this advance directive can create ethical dilemmas specifically involving patient autonomy and the physician's responsibility to do no harm.

METHODS

This paper discusses the ethical considerations regarding perioperative DNR orders and provides guidance on how to handle situations that may arise in the conduct of perioperative care.

RESULTS

Because of the potential conflicts between ethical care and the restrictions of DNR orders, it is critically important to discuss the medical and ethical issues surrounding this clinical scenario with the patient or surrogate prior to any surgical intervention. However, many anesthesiologists do not adequately address this ethical dilemma prior to the procedure.

CONCLUSION

Practitioners are advised to first consider what is best for the patient and, when in doubt, to communicate with patients or surrogates and with colleagues to arrive at the most appropriate care plan. If irreconcilable conflicts arise, consultation with the institution's bioethics committee, if available, is beneficial to help reach a resolution.

Predictors of survival from perioperative cardiopulmonary arrests: a retrospective analysis of 2,524 events from the Get With The Guidelines-Resuscitation registry

BACKGROUND

Perioperative cardiopulmonary arrests are uncommon and little is known about rates and predictors of in-hospital survival.

METHODS

Using the Get With The Guidelines®-Resuscitation national in-hospital resuscitation registry, we identified all patients aged 18 yr or older who experienced an index, pulseless cardiac arrest in the operating room or within 24 h postoperatively. The primary outcome was survival to hospital discharge, and the secondary outcome was neurologically intact recovery among survivors. Multivariable logistic regression models using generalized estimating equation models were used to identify independent predictors of survival and neurologically intact survival.

RESULTS

A total of 2,524 perioperative cardiopulmonary arrests were identified from 234 hospitals. The overall rate of survival to discharge was 31.7% (799/2,524), including 41.8% (254/608) for ventricular tachycardia and ventricular fibrillation, 30.5% (296/972) for asystole, and 26.4% (249/944) for pulseless electrical activity. Ventricular fibrillation and pulseless ventricular tachycardia were independently associated with improved survival. Asystolic arrests occurring in the operating room and postanesthesia care unit were associated with improved survival when compared to other perioperative locations. Among patients with neurological status assessment at discharge, the rate of neurologically intact survival was 64.0% (473/739). Prearrest neurological status at admission, patient age, inadequate natural airway, prearrest ventilatory support, duration of event, and event location were significant predictors of neurological status at discharge.

CONCLUSION

Among patients with a perioperative cardiac arrest, one in three survived to hospital discharge, and good neurological outcome was noted in two of three survivors.

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.

"This is a decision you have to make": using simulation to study prenatal counseling

INTRODUCTION

Prenatal decision making during extremely preterm labor is challenging for parents and physicians. Ethical and logistical concerns have limited empirical descriptions of physician counseling behaviors in this setting and constricted opportunities for communication training. This pilot study examines how simulation might be used to engage neonatologists in reflecting on their usual prenatal counseling behaviors.

METHODS

Neonatology physicians counseled a couple (standardized patients) with the female patient having impending delivery at 23 3/7 weeks. Encounters were videotaped. Physicians completed postencounter surveys and debriefing interviews. Mixed-methods analysis explored the outcomes of clinical verisimilitude and counseling behaviors.

RESULTS

All 10 neonatology physicians found that the simulation was highly realistic and that their behaviors paralleled neonatologist self-report in other studies. Physicians contributed more than 80% of encounter dialogue and mostly focused on biomedical information related to the acute perinatal period. Physicians spent nearly a quarter of each encounter in building relationships and expressing empathy. Most physicians initiated discussion about quality versus quantity of life but infrequently elicited the parents' related goals and values. When medical factors and family preferences were held constant, physicians assumed variable responsibility for making decisions about resuscitation. Most physicians declined parent requests for treatment recommendations, although all of those physicians felt more than 75% certain about what should be done.

CONCLUSIONS

Simulation can reproduce the decisional context of prenatal counseling for extremely premature labor. These results have implications for communication training in any setting where physicians and patients without established relationships must discuss acute diagnoses and make high-stakes medical decisions.

Simulation and quality improvement in anesthesiology

Simulation, a strategy for improving the quality and safety of patient care, is used for the training of technical and nontechnical skills and for training in teamwork and communication. This article reviews simulation-based research, with a focus on anesthesiology, at 3 different levels of outcome: (1) as measured in the simulation laboratory, (2) as measured in clinical performance, and (3) as measured in patient outcomes. It concludes with a discussion of some current uses of simulation, which include the identification of latent failures and the role of simulation in continuing professional practice assessment for anesthesiologists.