The intersection of prognostication and code status in patients with severe brain injury

Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate and variable. Overly optimistic prognostication can lead to false hope and futile care. Overly pessimistic prognostication can lead to therapeutic nihilism. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do Not Resuscitate orders has been shown to be associated with increased mortality. Based on a comprehensive search of peer-reviewed journals using a wide range of key terms, including prognostication, critical illness, brain injury, cognitive bias, and code status, the following is a review of prognostic accuracy and the effect of code status on outcome. Because withdrawal of treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication and code status is needed.

The Do Not Resuscitate (DNR) order in the perioperative setting: practical considerations

PURPOSE OF REVIEW

Addressing patients' Do Not Resuscitate (DNR) status in the perioperative setting is important for shared patient decision-making. Although the inherently resuscitative nature of anesthesia and surgery may pose an ethical quandary for clinicians tasked with caring for the patient, anesthesiologist-led efforts need to evaluate all aspects of the DNR order and operative procedures.

RECENT FINDINGS

Approximately 15% of patients undergoing surgical procedures have a preexisting DNR order (Margolis et al., 1995) [1]. American Society of Anesthesiologists (ASA) and the American College of Surgeons (ACS) do not support automatic reversal of the DNR order in the perioperative setting. Citing patient self-determination and autonomy, these societies advocate for a thoughtful discussion where a patient or legal designee may make an informed decision regarding resuscitation in the perioperative setting. Although studies have suggested increased perioperative mortality among patients with a preexisting DNR order, this data remains largely inconclusive.

SUMMARY

Efforts must be made to address the DNR order in the perioperative setting. The fundamental tenets of medical ethics, nonmaleficence, beneficence, and patient autonomy can help to guide this oftentimes challenging discussion.