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Hadler R, India L, Bader AM, Farber ON, Fritz ML, Johnston FM, Massarweh NN, Pathak R, Sacks SH, Schwarze ML, Streid J, Rosa WE, Aslakson RA. Top Ten Tips Palliative Care Clinicians Should Know Before Their Patient Undergoes Surgery? J Palliat Med 2024. [PMID: 39008413 DOI: 10.1089/jpm.2024.0222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024] Open
Abstract
Many seriously ill patients undergo surgical interventions. Palliative care clinicians may not be familiar with the nuances involved in perioperative care, however they can play a valuable role in enabling the delivery of patient-centered and goal-concordant perioperative care. The interval of time surrounding a surgical intervention is fraught with medical, psychosocial, and relational risks, many of which palliative care clinicians may be well-positioned to navigate. A perioperative palliative care consult may involve exploring gaps between clinician and patient expectations, facilitating continuity of symptom management or helping patients to designate a surrogate decision-maker before undergoing anesthesia. Palliative care clinicians may also be called upon to direct discussions around perioperative management of modified code status orders and to engage around the goal-concordance of proposed interventions. This article, written by a team of surgeons and anesthesiologists, many with subspecialty training in palliative medicine and/or ethics, offers ten tips to support palliative care clinicians and facilitate comprehensive discussion as they engage with patients and clinicians considering surgical interventions.
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Affiliation(s)
- Rachel Hadler
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Geriatrics and Extended Care, Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Lara India
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Angela M Bader
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Orly N Farber
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Melanie L Fritz
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Fabian M Johnston
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nader N Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Ravi Pathak
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sandra H Sacks
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Margaret L Schwarze
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jocelyn Streid
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Rebecca A Aslakson
- Department of Anesthesiology, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
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Hardin JB, Erickson JM. Directives Limiting Care in the Perianesthesia Setting: A Foucauldian Case Study Report. J Perianesth Nurs 2024; 39:439-446.e9. [PMID: 37988034 DOI: 10.1016/j.jopan.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 08/31/2023] [Accepted: 09/14/2023] [Indexed: 11/22/2023]
Abstract
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.
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Affiliation(s)
- Joshua B Hardin
- Department of Nursing, Inver Hills Community College, Inver Grove Heights, MN.
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Tanious M, Lindvall C, Cooper Z, Tukan N, Peters S, Streid J, Fields K, Bader A. Prevalence, Management, and Outcomes Related to Preoperative Medical Orders for Life Sustaining Treatment (MOLST) in an Adult Surgical Population: Preoperative MOLST and Code Status Discussions. Ann Surg 2023; 277:109-115. [PMID: 33351480 DOI: 10.1097/sla.0000000000004675] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine prevalence of documented preoperative code status discussions and postoperative outcomes (specifically mortality, readmission, and discharge disposition) of patients with completed MOLST forms before surgery. SUMMARY OF BACKGROUND DATA A MOLST form documents patient care preference regarding treatment limitations. When considering surgery in these patients, preoperative discussion is necessary to ensure concordance of care. Little is known about prevalence of these discussions and postoperative outcomes. METHODS A retrospective cohort study was conducted consisting of all patients having surgery during a 1-year period at a tertiary care academic center in Boston, Massachusetts. RESULTS Among 21,787 surgical patients meeting inclusion criteria, 402 (1.8%) patients had preoperative MOLST. Within the MOLST, 224 (55.7%) patients had chosen to limit cardiopulmonary resuscitation and 214 (53.2%) had chosen to limit intubation and mechanical ventilation. Code status discussion was documented presurgery in 169 (42.0%) patients with MOLST. Surgery was elective or nonurgent for 362 (90%), and median length of stay (Q1, Q3) was 5.1 days (1.9, 9.9). The minority of patients with preoperative MOLST were discharged home [169 (42%), and 103 (25.6%) patients were readmitted within 30 days. Patients with preoperative MOLST had a 30-day mortality of 9.2% (37 patients) and cumulative 90-day mortality of 14.9% (60 patients). CONCLUSIONS Fewer than half of surgical patients with preoperative MOLST have documented code status discussions before surgery. Given their high risk of postoperative mortality and the diversity of preferences found in MOLST, thoughtful discussion before surgery is critical to ensure concordant perioperative care.
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Affiliation(s)
- Mariah Tanious
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina
| | - Charlotta Lindvall
- Department of Palliative Medicine, Dana Farber Cancer Institute, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Department of Palliative Medicine, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Natalie Tukan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Peters
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jocelyn Streid
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kara Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Angela Bader
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Bernacki GM, Starks H, Krishnaswami A, Steiner JM, Allen MB, Batchelor WB, Yang E, Wyman J, Kirkpatrick JN. Peri-procedural code status for transcatheter aortic valve replacement: Absence of program policies and standard practices. J Am Geriatr Soc 2022; 70:3378-3389. [PMID: 35945706 PMCID: PMC9771878 DOI: 10.1111/jgs.17980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/31/2022] [Accepted: 07/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Little is known about policies and practices for patients undergoing Transcatheter Aortic Valve Replacement (TAVR) who have a documented preference for Do Not Resuscitate (DNR) status at time of referral. We investigated how practices across TAVR programs align with goals of care for patients presenting with DNR status. METHODS Between June and September 2019, we conducted semi-structured interviews with TAVR coordinators from 52/73 invited programs (71%) in Washington and California (TAVR volume > 100/year:34%; 50-99:36%; 1-50:30%); 2 programs reported no TAVR in 2018. TAVR coordinators described peri-procedural code status policies and practices and how they accommodate patients' goals of care. We used data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, stratified by programs' DNR practice, to examine differences in program size, patient characteristics and risk status, and outcomes. RESULTS Nearly all TAVR programs (48/50: 96%) addressed peri-procedural code status, yet only 26% had established policies. Temporarily rescinding DNR status until after TAVR was the norm (78%), yet time frames for reinstatement varied (38% <48 h post-TAVR; 44% 48 h-to-discharge; 18% >30 days post-discharge). For patients with fluctuating code status, no routine practices for discharge documentation were well-described. No clinically substantial differences by code status practice were noted in Society of Thoracic Surgeons Predicted Risk of Mortality risk score, peri-procedural or in-hospital cardiac arrest, or hospice disposition. Six programs maintaining DNR status recognized TAVR as a palliative procedure. Among programs categorically reversing patients' DNR status, the rationale for differing lengths of time to reinstatement reflect divergent views on accountability and reporting requirements. CONCLUSIONS Marked heterogeneity exists in management of peri-procedural code status across TAVR programs, including timeframe for reestablishing DNR status post-procedure. These findings call for standardization of DNR decisions at specific care points (before/during/after TAVR) to ensure consistent alignment with patients' health-related goals and values.
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Affiliation(s)
- Gwen M Bernacki
- Division of Cardiology, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
- Division of Cardiology, Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Helene Starks
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Ashok Krishnaswami
- Kaiser Permanente San Jose Medical Center, San Jose, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Division of Geriatrics, Stanford, Palo Alto, California, USA
| | - Jill M Steiner
- Division of Cardiology, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Matthew B Allen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Eugene Yang
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Janet Wyman
- Henry Ford Health System, Center for Structural Heart Disease, Detroit, Michigan, USA
| | - James N Kirkpatrick
- Division of Cardiology, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
- Division of Geriatrics, Stanford, Palo Alto, California, USA
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Jones S, Mulaikal TA. End of Life: What Is the Anesthesiologist's Role? Adv Anesth 2022; 40:1-14. [PMID: 36333041 DOI: 10.1016/j.aan.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Stephanie Jones
- Columbia University Irving Medical Center, Division of Critical Care Medicine, 622 W. 168th St, New York, NY 10032, USA
| | - Teresa A Mulaikal
- Division of Cardiothoracic and Critical Care, Columbia University Medical Center, 622 W. 168th St., PH 5 Stem 133, New York, NY 10032, USA.
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Parental request for non-resuscitation in fetal myelomeningocele repair: an analysis of the novel ethical tensions in fetal intervention. J Perinatol 2022; 42:856-859. [PMID: 35031691 DOI: 10.1038/s41372-022-01317-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 11/08/2022]
Abstract
As the field of fetal intervention grows, novel ethical tensions will arise. We present a case of Fetal myelomeningocele repair involving a 25-week fetus where parents requested that if emergent delivery was necessary during the open uterine procedure, that the medical team did not perform resuscitation. This question brings forward an important discussion around the complicated space of maternal autonomy, child rights, and clinician obligations that exists in fetal intervention. In some regions, a mother in this situation may choose to terminate the pregnancy. Parents could also choose not to do the surgery. Parents in some regions could opt for no resuscitation of a child born at 25-weeks' gestation. We offer an analysis of these relevant considerations, the different tensions, and the conflicting duties between the mother, fetus, and medical team. This analysis will provide ethical and clinical guidance for future questions that may arise in this burgeoning field.
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7
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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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O'Leary S, Pimentel MP, Ford S, Vacanti JC, Bleday R, Salmasian H, Mendu ML. Perioperative Code Status Discussions: How Are We Doing? A A Pract 2021; 15:e01473. [PMID: 34043591 DOI: 10.1213/xaa.0000000000001473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Approximately 15% of patients with a code status of do-not-resuscitate (DNR) or do-not-intubate (DNI) present for surgery. Despite professional guidelines requiring discussions with patients regarding perioperative resuscitation, it is unclear whether these recommendations are consistently followed. Our review of 158 patient encounters with established DNR/DNI code status found that code status discussions (CSDs) were documented only 70% of the time, and code status orders were inconsistently entered to reflect those discussions. We present solutions to improve CSD documentation, including refining perioperative workflows, simplifying code status choices, optimizing electronic health record order entry, and a supplementary consent form to facilitate code status review.
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Affiliation(s)
- Sian O'Leary
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc Philip Pimentel
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Quality and Safety
| | - Shauna Ford
- Department of Analytics, Planning and Strategy Implementation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joshua C Vacanti
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ronald Bleday
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hojjat Salmasian
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Analytics, Planning and Strategy Implementation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mallika L Mendu
- Department of Quality and Safety
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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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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Robbins AJ, Ingraham NE, Sheka AC, Pendleton KM, Morris R, Rix A, Vakayil V, Chipman JG, Charles A, Tignanelli CJ. Discordant Cardiopulmonary Resuscitation and Code Status at Death. J Pain Symptom Manage 2021; 61:770-780.e1. [PMID: 32949762 PMCID: PMC8052631 DOI: 10.1016/j.jpainsymman.2020.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT One fundamental way to honor patient autonomy is to establish and enact their wishes for end-of-life care. Limited research exists regarding adherence with code status. OBJECTIVES This study aimed to characterize cardiopulmonary resuscitation (CPR) attempts discordant with documented code status at the time of death in the U.S. and to elucidate potential contributing factors. METHODS The Cerner Acute Physiology and Chronic Health Evaluation (APACHE) outcomes database, which includes 237 U.S. hospitals that collect manually abstracted data from all critical care patients, was queried for adults admitted to intensive care units with a documented code status at the time of death from January 2008 to December 2016. The primary outcome was discordant CPR at death. Multivariable logistic regression models were used to identify patient-level and hospital-level associated factors after adjustment for age, hospital, and illness severity (APACHE III score). RESULTS A total of 21,537 patients from 56 hospitals were included. Of patients with a do-not-resuscitate code status, 149 (0.8%) received CPR at death, and associated factors included black race, higher APACHE III score, or treatment in small or nonteaching hospitals. Of patients with a full code status, 203 (9.0%) did not receive CPR at death, and associated factors included higher APACHE III score, primary neurologic or trauma diagnosis, or admission in a more recent year. CONCLUSION At the time of death, 1.6% of patients received or did not undergo CPR in a manner discordant with their documented code statuses. Race and institutional factors were associated with discordant resuscitation, and addressing these disparities may promote concordant end-of-life care in all patients.
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Affiliation(s)
- Alexandria J Robbins
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
| | - Nicholas E Ingraham
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Adam C Sheka
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Kathryn M Pendleton
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Rachel Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alexander Rix
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Victor Vakayil
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA; Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis, Minnesota, USA
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11
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Kushelev M, Meyers LD, Palettas M, Lawrence A, Weaver TE, Coffman JC, Moran KR, Lipps JA. Perioperative do-not-resuscitate orders: Trainee experiential learning in preserving patient autonomy and knowledge of professional guidelines. Medicine (Baltimore) 2021; 100:e24836. [PMID: 33725954 PMCID: PMC7982162 DOI: 10.1097/md.0000000000024836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 01/25/2021] [Indexed: 01/05/2023] Open
Abstract
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.
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12
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Wong J, Gravely A, Duane PG. Management of Do Not Resuscitate Orders Before Invasive Procedures. Fed Pract 2021; 38:80-83. [PMID: 33716484 DOI: 10.12788/fp.0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Jennifer Wong
- is an Instructor, and is an Associate Professor, both at the University of Minnesota in Minneapolis. is a Research Service Biostatistician, and Peter Duane is an Associate Director of the Primary and Specialty Care Service Line in the Division of Pulmonary and Critical Care, both at the Minneapolis Veterans Affairs Health Care System
| | - Amy Gravely
- is an Instructor, and is an Associate Professor, both at the University of Minnesota in Minneapolis. is a Research Service Biostatistician, and Peter Duane is an Associate Director of the Primary and Specialty Care Service Line in the Division of Pulmonary and Critical Care, both at the Minneapolis Veterans Affairs Health Care System
| | - Peter G Duane
- is an Instructor, and is an Associate Professor, both at the University of Minnesota in Minneapolis. is a Research Service Biostatistician, and Peter Duane is an Associate Director of the Primary and Specialty Care Service Line in the Division of Pulmonary and Critical Care, both at the Minneapolis Veterans Affairs Health Care System
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13
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Ruisch JE, Sipers W, Plum PF, Spaetgens B. Individualized approach to reconsider perioperative do-not-resuscitate orders in frail older patients. Geriatr Gerontol Int 2020; 20:989-990. [PMID: 33003252 PMCID: PMC7590086 DOI: 10.1111/ggi.14030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/16/2020] [Indexed: 12/04/2022]
Affiliation(s)
- Jessica E Ruisch
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Geriatric Medicine, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Walther Sipers
- Department of Geriatric Medicine, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - P Frederik Plum
- Department of Geriatric Medicine, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Bart Spaetgens
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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14
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How do anesthesiologists and orthopedic surgeons manage do-not-resuscitate orders during surgery? A pilot study. Resuscitation 2019. [DOI: 10.1016/j.resuscitation.2019.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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15
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Weaver MS, Anderson B, Cole A, Lyon ME. Documentation of Advance Directives and Code Status in Electronic Medical Records to Honor Goals of Care. J Palliat Care 2019; 35:217-220. [PMID: 31280659 DOI: 10.1177/0825859719860129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advance care planning is a process that supports conversations about the values that matter most to patients and their family members. The documentation of advance directives and code status in a patient's electronic health record (EHR) is a critical step to ensure treatment preferences are honored in the medical care received. The current approach to advanced care planning documentation in electronic medical records often remains disparate within and across EHR systems. Without a standardized format for documentation or centralized location for documentation, advance directives and even code status content are often difficult to access within electronic medical records. This case report launched our palliative care team into partnership with the Information Technology team for implementation of a centralized, standardized, longitudinal, functional documentation of advance care planning and code status in the electronic medical record system.
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Affiliation(s)
- Meaghann S Weaver
- Division of Pediatric Palliative Care, 20635Children's Hospital and Medical Center Omaha, Omaha, NE, USA [Advocacy project took place in the location Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Omaha, NE, USA.]
| | - Betty Anderson
- Department of Information Technology, 20635Children's Hospital and Medical Center Omaha, Omaha, NE, USA
| | - Anne Cole
- Department of Information Technology, 20635Children's Hospital and Medical Center Omaha, Omaha, NE, USA
| | - Maureen E Lyon
- 233494Children's National Health System, Washington, DC, USA.,Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children's Research Institute, Children's National Health System, Washington, DC, USA.,Department of Pediatrics, 233494Children's National Health System, George Washington School of Medicine and Health Sciences, Washington, DC, USA
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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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17
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Hiestand D, Beaman M. Perioperative Do‐Not‐Resuscitate Suspension: The Patient's Perspective. AORN J 2019; 109:326-334. [DOI: 10.1002/aorn.12612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Fletcher JWA, Smith A, Walsh K, Riddick A. Low Rates of Survival Seen in Orthopedic Patients Receiving In-Hospital Cardiopulmonary Resuscitation. Geriatr Orthop Surg Rehabil 2019; 10:2151459318818972. [PMID: 30729062 PMCID: PMC6350114 DOI: 10.1177/2151459318818972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/10/2018] [Accepted: 11/13/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Despite awareness of overall poor survival rates following cardiopulmonary resuscitation (CPR), some orthopedic patients with significant comorbidities continue to have inappropriate resuscitation plans. Furthermore, in certain injury groups such as patients with hip fractures, survival outcome data are very limited; current discussions regarding resuscitation plans may be inaccurate. This study assesses survival in orthopedic patients following CPR, to inform decision-making between physicians, surgeons, and patients. METHODS A dual center, retrospective cohort study was performed analyzing all orthopedic admissions that received CPR over a 25-month period, with a minimum of 1 year follow-up. National Cardiac Arrest Audit data, "mortality and morbidity" meeting records, National Hip Fracture Databases, and electronic notes were analyzed. Survival duration was measured, alongside reason for admission, location CPR occurred, and initial rhythm encountered. RESULTS Thirty-two patients received CPR over the 25-month period (median age: 83; range: 30-96). Three (9%) of 32 patients survived to discharge. Only 1 of the 26 patients older than 65 years survived to discharge. Fifteen (47%) of 32 had hip fractures, where 4 (27%) of 15 of this group survived 24 hours; none survived to discharge. When recorded, 22 (92%) of 24 initially had a nonshockable rhythm. DISCUSSION Cardiopulmonary resuscitation was conceptualized as a treatment for reversible cardiopulmonary causes. When used in trauma and orthopedic patients, especially older and/or hip fracture patients, it seldom led to hospital discharge. Different admission practices such as "front door" orthogeriatric reviews may explain the contrast in usage of CPR between the hospitals. CONCLUSION Survival rates following CPR were very low, with it proving specifically ineffective in hip fracture patients. Although every decision about resuscitation should be patient centered and individualized, this study will allow clinicians to be more realistic about outcomes from CPR, particularly in the hip fracture group.
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Affiliation(s)
- James W. A. Fletcher
- Department for Health, University of Bath, Bath, United Kingdom
- Severn Postgraduate Medical Education School of Surgery, Bristol, United
Kingdom
| | - Adam Smith
- Severn Postgraduate Medical Education School of Surgery, Bristol, United
Kingdom
- Royal United Hospitals Bath NHS Foundation Trust, Bath, United Kingdom
| | - Katherine Walsh
- Department of Geriatric Medicine, North Bristol NHS Trust, Bristol, United
Kingdom
| | - Andrew Riddick
- Department of Trauma & Orthopaedics, North Bristol NHS Trust, Bristol,
United Kingdom
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19
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Urman RD, Lilley EJ, Changala M, Lindvall C, Hepner DL, Bader AM. A Pilot Study to Evaluate Compliance with Guidelines for Preprocedural Reconsideration of Code Status Limitations. J Palliat Med 2018; 21:1152-1156. [DOI: 10.1089/jpm.2017.0601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Richard D. Urman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Perioperative Research, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth J. Lilley
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Marguerite Changala
- School of Medicine, University of California San Francisco, San Francisco, California
| | - Charlotta Lindvall
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - David L. Hepner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Angela M. Bader
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
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20
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Cobert J, Hauck J, Flanagan E, Knudsen N, Galanos A. Anesthesia-Guided Palliative Care in the Perioperative Surgical Home Model. Anesth Analg 2018; 127:284-288. [DOI: 10.1213/ane.0000000000002775] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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21
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Bakke KE, Miranda SP, Castillo-Angeles M, Cauley CE, Lilley EJ, Bernacki R, Bader AM, Urman RD, Cooper Z. Training Surgeons and Anesthesiologists to Facilitate End-of-Life Conversations With Patients and Families: A Systematic Review of Existing Educational Models. JOURNAL OF SURGICAL EDUCATION 2018; 75:702-721. [PMID: 28939306 DOI: 10.1016/j.jsurg.2017.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 07/17/2017] [Accepted: 08/07/2017] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Katherine E Bakke
- Department of Surgery, University of Massachusetts Medical School, Massachusetts, USA
| | - Stephen P Miranda
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Manuel Castillo-Angeles
- Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christy E Cauley
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth J Lilley
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Rachelle Bernacki
- Department of Palliative Care and Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Angela M Bader
- Department of Surgery, University of Massachusetts Medical School, Massachusetts, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Center for Perioperative Research, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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Abstract
OBJECTIVE To describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. BACKGROUND Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. METHODS The National Institutes of Health and the National Palliative Care Research Center convened researchers from several medical subspecialties to develop a national agenda for palliative care research. The surgeon work group reviewed the existing surgical literature to identify critical knowledge gaps. RESULTS To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. Priorities for future research on palliative care in surgery include: 1) measuring outcomes that matter to patients, 2) communication and decision making, and 3) delivery of palliative care to surgical patients. CONCLUSIONS Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social and spiritual well-being and quality of life. We propose a research agenda to address major gaps in the literature and provide a road map for future investigation.
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23
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Do-Not-Resuscitate Orders in the Perioperative Environment: A Multidisciplinary Quality Improvement Project. AORN J 2017; 106:20-30. [PMID: 28662781 DOI: 10.1016/j.aorn.2017.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 11/12/2016] [Accepted: 05/03/2017] [Indexed: 12/21/2022]
Abstract
Do-not-resuscitate (DNR) orders in the perioperative environment must be managed according to national and institutional guidelines. Health care professionals, including perioperative nurses, may be unfamiliar with the guidelines and unsure of their role in reevaluating a DNR order. We conducted a multidisciplinary quality improvement project at a metropolitan community hospital that aimed to improve health care providers' compliance with the institutional policy, nursing involvement in DNR reevaluation, and communication between providers. The project intervention was an educational fair preceded and followed by a survey measuring knowledge about DNR orders, institutional policy, and national guidelines; attitude toward and comfort with the reevaluation process; and the effectiveness of the communication processes. Knowledge of DNR orders improved (P < .0001) for three of four survey questions. Attitude, comfort, and communication also improved (P < .01). A chart audit two months after the intervention showed that compliance with the institutional policy increased by 75%.
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24
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White P, Cobb D, Vasilopoulos T, Davies L, Fahy B. End-of-life discussions: Who's doing the talking? J Crit Care 2017; 43:70-74. [PMID: 28846896 DOI: 10.1016/j.jcrc.2017.08.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 08/18/2017] [Accepted: 08/19/2017] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Peggy White
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Danielle Cobb
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Terrie Vasilopoulos
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA; Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Laurie Davies
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Brenda Fahy
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA.
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25
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Lilley EJ, Cooper Z, Schwarze ML, Mosenthal AC. Palliative Care in Surgery: Defining the Research Priorities. J Palliat Med 2017; 20:702-709. [PMID: 28339313 DOI: 10.1089/jpm.2017.0079] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet, these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social, and spiritual well-being and quality of life. To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. The objective of this article was to describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. We propose a research agenda to address these gaps and provide a road map for future investigation.
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Affiliation(s)
- Elizabeth J Lilley
- 1 The Center for Surgery and Public Health at Brigham and Women's Hospital , Boston, Massachusetts
| | - Zara Cooper
- 1 The Center for Surgery and Public Health at Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Margaret L Schwarze
- 3 Department of Surgery, University of Wisconsin , Madison, Wisconsin.,4 Department of Medical History and Bioethics, University of Wisconsin , Madison, Wisconsin
| | - Anne C Mosenthal
- 5 Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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26
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[Pre-operative documentation of individual in-patient therapy goals : A medical staff questionnaire]. Anaesthesist 2016; 65:499-506. [PMID: 27324155 DOI: 10.1007/s00101-016-0180-5] [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: 02/06/2016] [Revised: 04/10/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Perioperative care demands consideration of individual treatment goals. We evaluated the attitudes of medical staff towards a short standardized advance directive (SSAD) as a means of improving patient-orientated care at the transition from operating theater to general or intensive care wards. METHOD Multicenter anonymized standardized multiple-choice questionnaire among physicians and nurses from various operative and anesthesiology departments. Questions addressing demographic parameters and attitudes towards advance directives in acute care settings (eleven 4‑stepped Likert items). Univariate analysis of group comparisons using the chi-square and Kruskal-Wallis rank-sum test. Multivariable analysis of significant differences employing ordinal logistic regression. RESULTS The overall return rate was 28.2 % (169 questionnaires). Of these, 19.5 % said that existing advance directives were regularly reassessed preoperatively. SSAD was expected to provide improved emergency care by 82.3 and 76.6 % thought that it would help to better focus intensive care resources according to patients' needs. DISCUSSION Our study shows the dilemma of insufficiently structured directives for changing treatment goals as well as a high number of legal procedures to obtain proxy decisions due to missing out-patient advance health planning. From a medical staff perspective there is strong support for the concept of SSAD based on medical, ethical, economic and organizational reasons.
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Editorial: Do-Not-Resuscitate Orders and Advance Directives--Existential Issues for Orthopaedic Patients with Life-threatening Conditions. Clin Orthop Relat Res 2016; 474:867-70. [PMID: 26769617 PMCID: PMC4773333 DOI: 10.1007/s11999-015-4687-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 12/28/2015] [Indexed: 01/31/2023]
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Abstract
Abstract
Automatic suspension of do-not-resuscitate (DNR) orders during general anesthesia does not sufficiently address a patient’s right to self-determination and is a practice still observed among anesthesiologists today. To provide an evidence base for ethical management of DNR orders during anesthesia and surgery, the authors performed a systematic review of the literature to quantify the survival after perioperative cardiopulmonary resuscitation (CPR). Results show that the probability of surviving perioperative CPR ranged from 32.0 to 55.7% when measured within the first 24 h after arrest with a neurologically favorable outcome expectancy between 45.3 and 66.8% at follow-up, which suggests a viable survival of approximately 25%. Because CPR generally proves successful in less than 15% of out-of-hospital cardiac arrests, the altered outcome probabilities that the conditions in the operating room bring on warrant reevaluation of DNR orders during the perioperative period. By preoperatively communicating the evidence to patients, they can make better informed decisions while reducing the level of moral distress that anesthesiologists may experience when certain patients decide to retain their DNR orders.
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29
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Sumrall WD, Mahanna E, Sabharwal V, Marshall T. Do Not Resuscitate, Anesthesia, and Perioperative Care: A Not So Clear Order. Ochsner J 2016; 16:176-179. [PMID: 27303230 PMCID: PMC4896664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
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.
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Affiliation(s)
- William D. Sumrall
- Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA
| | - Elizabeth Mahanna
- Department of Neuro Critical Care, Ochsner Clinic Foundation, New Orleans, LA
| | - Vivek Sabharwal
- Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Thomas Marshall
- Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA
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30
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Lassen CL, Aberle S, Lindenberg N, Bundscherer A, Klier TW, Graf BM, Wiese CH. Palliative patients under anaesthesiological care: a single-centre retrospective study on incidence, demographics and outcome. BMC Anesthesiol 2015; 15:164. [PMID: 26566813 PMCID: PMC4644289 DOI: 10.1186/s12871-015-0143-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 11/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While anesthesiologist's involvement in palliative care has been widely researched, extensive data on palliative patients under anesthesiological care in the operating room is missing. This study was performed to assess the incidence, demographics, and outcome of palliative patients under anesthesiological care. METHODS We conducted a single-center retrospective chart review of all palliative patients under anesthesiological care at a university hospital in 1 year. Patients were classified as palliative if they fulfilled all predefined criteria (a) incurable, life-threatening disease, (b) progression of the disease despite therapy, (c) advanced stage of the disease with limited life-expectancy, (d) receiving or being in need of a specific palliative therapy. Demographics, periprocedural parameters, symptoms at evaluation, and outcome were determined using different medical records. RESULTS Of 17,580 patients examined, 276 could be classified as palliative patients (1.57%). Most contacts with palliative patients occurred in the operating room (68.5%). In comparison to the non-palliative patients, procedures in palliative patients were significantly more often urgent or emergency procedures (39.1% vs. 27.1%., P < 0.001), and hospital mortality was higher (18.8% vs. 5.0%, P < 0.001). Preprocedural symptoms varied, with pain, gastrointestinal, and nutritional problems being the most prevalent. CONCLUSIONS Palliative patients are treated by anesthesiologists under varying circumstances. Anesthesiologists need to identify these patients and need to be aware of their characteristics to adequately attend to them during the periprocedural period.
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Affiliation(s)
- Christoph L Lassen
- Department of Anaesthesiology, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
| | - Susanne Aberle
- Department of Anaesthesiology, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany. .,Department of Nuclear Medicine, University Hospital of Zurich, Raemistrasse, Zurich, Switzerland.
| | - Nicole Lindenberg
- Department of Anaesthesiology, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
| | - Annika Bundscherer
- Department of Anaesthesiology, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
| | - Tobias W Klier
- Department of Anaesthesiology, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
| | - Bernhard M Graf
- Department of Anaesthesiology, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
| | - Christoph H Wiese
- Department of Anaesthesiology, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
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Evaluation of older Adults with obesity for bariatric surgery: Geriatricians' perspective. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.jcgg.2015.01.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Khalaileh MA. Jordanian critical care nurses' attitudes toward and experiences of do not resuscitate orders. Int J Palliat Nurs 2014; 20:403-8. [PMID: 25151868 DOI: 10.12968/ijpn.2014.20.8.403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Do not resuscitate (DNR) decisions are an issue of considerable sensitivity for patients and their relatives, as well as health professionals. PURPOSE The aim of this study was to explore Jordanian critical care nurses' attitudes towards and experiences of DNR decisions in clinical practice. METHODS A cross-sectional survey design was used. The sample consisted of 111 nurses working in intensive care units in three government hospitals in Jordan. RESULTS Fifty nine per cent of the participants were female. Most were under the age of 35 (69%) and 75% had a bachelor's degree. Most (67%) thought that the patient's family should be involved in DNR decision making. The majority (81%) reported that they preferred a coding system documenting DNR decisions in either the physician or nursing notes. Fifty eight per cent agreed that a standard DNR form should be kept with the patient's medical notes. Only 21% reported actual participation in DNR decisions. CONCLUSION This study demonstrates that Jordanian critical care nurses are willing to participate in DNR discussions and decision-making processes. Each hospital in the country should have a written DNR policy to guide and discipline health-care providers' practice.
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Affiliation(s)
- Murad Al Khalaileh
- Assistant Professor, School of Nursing, Al al-Bayt University, PO Box 130040, Mafraq 25113, Jordan
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Hooper VD. Patient Experience as a Priority. J Perianesth Nurs 2014; 29:339-41. [DOI: 10.1016/j.jopan.2014.08.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gebauer SL, Fine PG. Palliative medicine competencies for anesthesiologists. J Clin Anesth 2014; 26:429-31. [PMID: 25200705 DOI: 10.1016/j.jclinane.2014.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/27/2014] [Accepted: 06/07/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Sarah L Gebauer
- Department of Anesthesiology, University of New Mexico, Albuquerque, NM 87106.
| | - Perry G Fine
- Pain Research and Management Centers, School of Medicine, University of Utah, Salt Lake City, UT 84132, USA
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Nurok M, Green DS, Chisholm MF, Fins JJ, Liguori GA. Anesthesiologists’ familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting. J Clin Anesth 2014; 26:174-6. [DOI: 10.1016/j.jclinane.2013.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 10/24/2013] [Accepted: 11/13/2013] [Indexed: 11/24/2022]
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Waisel DB. Unrecognized barriers to perioperative limitations on potentially life-sustaining medical treatment. J Clin Anesth 2014; 26:171-3. [DOI: 10.1016/j.jclinane.2014.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 01/12/2014] [Accepted: 01/14/2014] [Indexed: 11/27/2022]
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Jones JW, McCullough LB. Defining, aligning, or declining do not resuscitate during surgery. J Vasc Surg 2014; 59:1152-3. [PMID: 24661898 DOI: 10.1016/j.jvs.2014.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A Professor A. Droit, 93 years of age, formerly your college ethics teacher, developed a painful ischemic foot from distal aortic blockage. A daughter, who is a nurse, brought him to the hospital. He has multiple comorbidities, including leukemia for which he is getting chemotherapy. He agrees to surgery but hands you a completed do not resuscitate (DNR) form and insists it be honored throughout his care. As the operative wound is being closed, he has a slow ventricular tachycardia, which does not respond to intravenous therapy. You should:
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Affiliation(s)
- James W Jones
- The Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Tex.
| | - Laurence B McCullough
- The Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Tex
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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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