'Do not attempt resuscitation' orders in the peri-operative period

Resuscitation orders in the perioperative setting: A survey of knowledge, practices and perceptions among consultant and trainee anaesthesiologists

BACKGROUND

As advance healthcare directives gain clarity in state legislation in Ireland, anaesthesiologists will come across patients with resuscitation orders that will demand interpretation when encountered perioperatively. Studies show variable perceptions among anaesthesiologists towards the binding nature of resuscitation orders in the context of anaesthesia provision. Currently, knowledge, perceptions and practices of anaesthesiologists in Ireland towards such orders are not known.

METHODS

A cross-sectional online survey was distributed to anaesthesiologists in adult teaching hospitals.

RESULTS

In this cohort, 65.9% of those surveyed did not know if there was a local hospital policy advance healthcare directive containing, do not attempt resuscitation, decisions in the perioperative period in their current hospital; 57.7% did not know if there was a policy for not for resuscitation orders; 74.8% did not know if there are guidelines for the management of patients with resuscitation orders. Irrespective of the presence of an order stating otherwise, 43.9% would initiate resuscitation in the event of any arrest occurring in theatre, with 66.7% initiating resuscitation if secondary to iatrogenesis.

CONCLUSIONS

By uncovering low self-perceived levels of knowledge and mixed perceptions towards resuscitation orders, the authors hope that the study initiates much-needed conversations on the topic, particularly at a time when advance healthcare directives find a more firm legal footing in Ireland.

Hip Fracture in the Elderly Patients: A Sentinel Event

IMPORTANCE

Hip fracture in the elderly patients is associated with increased morbidity and mortality. There is great need for advance care planning should a patient fail to rehabilitate or experience an adverse event during or after recovery. This study was performed to evaluate for palliative care consultation and changes in code status and/or advance directives in elderly patients with hip fracture.

METHODS

We performed a retrospective review of 186 consecutive patients aged 65 years and older with a hip fracture due to a low-energy fall who underwent surgery at a large academic institution between August 1, 2013, and September 1, 2014. Risk factors assessed were patient demographics, home status, mobility, code status, comorbidities, medications, and hospitalizations prior to injury. Outcomes of interest included palliative care consultation, complications, mortality, and most recent code status, mobility, and home.

RESULTS

About 186 patients with hip fractures were included. Three patients died, and 12 (6.5%) sustained major complications during admission. Nearly one-third (51 patients) died upon final follow-up approximately 1.5 years after surgery. Of the patients who died, palliative care consulted on 6 (11.8%) during initial admission. Eleven (21.6%) were full code at death. Three patients underwent cardiopulmonary resuscitation (CPR) and 1 underwent massive transfusion and extracorporeal membrane oxygenation prior to changing their code status to do not attempt resuscitation.

CONCLUSION

Hip fracture in elderly patients is an important opportunity to reassess the patient's personal health-care priorities. Advance directives, goals of care, and code status documentation should be updated in all elderly patients with hip fracture, should the patient's health decompensate.

A survey of Australian and New Zealand anaesthetists' attitudes towards resuscitation orders in the perioperative setting

Not for resuscitation (NFR) orders are often suspended during anaesthesia, as perioperative care is believed to inherently involve the need for resuscitation including ventilation support. Recent legislative changes in Australia, New Zealand and the UK have enacted the binding nature of advance care directives (ACDs) in healthcare. National guidelines regarding codes of practice and government strategic plans for implementing advance care planning have reinforced the role for advance care planning in modern healthcare. We surveyed a random selection of Australian and New Zealand consultant and trainee anaesthetists to assess their attitudes towards NFR orders and ACDs in the perioperative setting. We received 290 of 790 distributed surveys (37% response rate). The majority (75%) of respondents reported their knowledge as very low, low, or moderate; 37% never or rarely were treating a patient who had an ACD. Over 90% reported that patient's wishes and understanding of ACDs is important and 89% agreed or strongly agreed that advance care planning should be a routine part of hospital admission for high risk patients. Despite this, only 45% of the respondents would always follow an ACD. Although the majority of respondents to this survey support their use in the perioperative setting, clarification of the specific applicability of ACDs to anaesthesia and their binding nature is required.

Management of 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decisions in the perioperative period

It is increasingly common for patients to be scheduled for anaesthesia and surgery with a 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decision in place. Updated guidelines for the implementation and management of DNACPR decisions were published jointly by the British Medical Association (BMA), the Resuscitation Council (UK) and the Royal College of Nursing (RCN) in 2014 (BMA, RC(UK), RCN 2014). The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published specific guidelines in 2009 to guide the perioperative management of such patients (AAGBI 2009). In this article, we explain these guidelines with a focus on how DNACPR decisions are made and how they can be modified in order to permit appropriate surgery to take place.

'Do Not Attempt Resuscitation' (DNAR) decisions in patients with femoral fractures: modification, clinical management and outcome

BACKGROUND

increased provision of orthogeriatric expertise for patients with femoral fractures has led to implementation of 'Do Not Attempt Resuscitation' (DNAR) decisions prior to anaesthesia and surgery for fixation of their fractures. Review and modification of the DNAR decision by the medical team is necessary before surgery and is recommended by guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the General Medical Council.

METHODS

over a 17-month period, DNAR decisions were already present or were implemented for the first time in 22 patients prior to scheduled surgical fixation of their femoral fractures. Data were collected prospectively on each patient's management, including modification of their DNAR decision, and outcome at 30 days and 1 year.

RESULTS

two patients died prior to surgery. In eight of the 20 patients who underwent surgical fixation, there was no documentation regarding the status of the DNAR decision in the perioperative period. The 30-day mortality rate for those undergoing surgery was 15% (3/20). At 1 year, eight patients survived with six living in their own homes.

CONCLUSIONS

despite the favourable outcomes for hip fracture patients with pre-existing DNAR decisions, this audit showed inadequate review and documentation of the DNAR decision in advance of surgery.

Pediatric DNAR orders in the perioperative period

Do not attempt resuscitation (DNAR) orders are a formal expression of the intention to refrain from resuscitation. Since their inception in 1974, such orders have become widely accepted within the hospital setting. However, their acceptance in theatres where anesthesia may cause cardiovascular instability, outcomes from cardiac arrest are improved and when there is a cross-over of techniques between anesthetic practice and resuscitation, has been more problematic. In order to ascertain the opinions on DNAR orders in the perioperative period, a questionnaire was sent to all consultant members of the Association of Paediatric Anaesthetists of Great Britain and Ireland, which asked about DNAR orders, resuscitation under anesthesia and included a number of case studies. Of the 280 respondents, 160 (57.1%) agreed that an anesthetist could alter the order in the perioperative period with 41 (14.6%) stating that they would always suspend such an order. Most anesthetists agreed that they would discuss DNAR orders during their preoperative assessment but could not agree as to which interventions constituted normal anesthetic practice as opposed to resuscitation. At present, there is variation in practice between pediatric anesthetists over suspension of DNAR orders in the perioperative period and no specific guidelines to refer to. We suggest that guidelines be produced and that these should take into account the work that has already taken place and guidelines published by other anesthetic communities.