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Crowe AM, Marsh B. Resuscitation orders in the perioperative setting: A survey of knowledge, practices and perceptions among consultant and trainee anaesthesiologists. J Perioper Pract 2023; 33:68-75. [PMID: 34375122 DOI: 10.1177/17504589211022310] [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: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Ann-Marie Crowe
- Department of Anaesthesiology, Critical Care and Pain Medicine, Mater Misericordiae University Hospital (MMUH), Dublin, Ireland
| | - Brian Marsh
- Department of Anaesthesiology, Critical Care and Pain Medicine, Mater Misericordiae University Hospital (MMUH), Dublin, Ireland
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2
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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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3
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Beyond the Do-not-resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients. Anesthesiology 2021; 135:781-787. [PMID: 34499085 DOI: 10.1097/aln.0000000000003937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, "full code" is the default option irrespective of clinical circumstances and patient preferences. It is time to revisit this approach based on (1) increasing understanding of the power of default options in healthcare settings, (2) changing demographics and growing evidence suggesting that an expanding subset of patients is vulnerable to poor outcomes after perioperative cardiopulmonary resuscitation (CPR), and (3) recommendations from multiple societies promoting risk assessment and goal-concordant care in older surgical patients. The authors reconsider current guidelines in the context of these developments and advocate for an expanded approach to decision-making regarding CPR, which involves identifying high-risk elderly patients and eliciting their preferences regarding CPR irrespective of existing or presumed code status.
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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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5
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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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6
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Affiliation(s)
- Preeti R John
- Veterans Affairs (VA) Maryland Healthcare System, Department of Surgery, 186153University of Maryland School of Medicine, Baltimore, USA
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7
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Banja J, Sumler M. Overriding advance directives: A 20-year legal and ethical overview. J Healthc Risk Manag 2019; 39:11-18. [PMID: 31433120 DOI: 10.1002/jhrm.21388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Health professionals have been known to override patients' advance directives. The most ethically problematic instances involve a directive's explicitly forbidding the administration of some life-prolonging treatment like resuscitation or intubation with artificial ventilation. Sometimes the code team is unaware of the directive, but in other instances, the override is done knowingly and intentionally with clinicians later pleading that it was done "in the patient's best interests." This article surveys a twenty-year period extending back to 1997 when ethicists began to question the legitimacy of overriding advance directives despite clinicians believing they had compelling reasons to do so. A legal and ethical analysis of advance directive overrides is provided as no court to date has awarded damages to plaintiffs who alleged their loved one suffered "wrongful life" following a successful life-prolonging intervention. A hypothetical scenario is especially discussed wherein a patient's DNR status is overridden because her cardiac arrest was caused by error whose effects might be reversible. The authors conclude with a strategy for mitigating certain vagaries associated with overriding advance directives, but suggest that until courts provide clinicians with clear guidelines and protections, violations of patients' advance directives are likely to continue.
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8
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Abstract
The role of the anesthesiologist cannot be understated when it comes to ethical decision making, especially at end of life. To best serve patients within the limits of the law, anesthesiologists must arm themselves with an understanding of how the laws surrounding ethical decision-making impact daily practices. It is also important to know what rights and duties a patient or surrogate has in the decision-making process. With proper understanding of their responsibilities and the available tools, anesthesiologists can fulfill their roles as leaders and advocates for their patients as approaches to ethical decision-making at the end of life evolve.
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Affiliation(s)
- Michael C Lewis
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health System, 2799 West Grand Boulevard, CFP 343, Detroit, MI 48202, USA
| | - Nicholas S Yeldo
- Educational Programs, Anesthesiology Residency, Henry Ford Health System, 2799 West Grand Boulevard, CFP 343, Detroit, MI 48202, USA.
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9
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Abstract
Surgeons, anesthesiologists, and nurses are frequently asked to operate on patients with an existing Do Not Resuscitate (DNR) order, resulting in confusion about the proper approach. We discuss the origins of decisions not to attempt resuscitation, the special circumstances surrounding the need for resuscitation intraoperatively, and reasons to suspend, or not suspend, the DNR order during the perioperative period. DNR should be part of a comprehensive discussion of a patient and family's goals of care. A clear understanding of those goals will lead the care team to a better understand the role of perioperative resuscitation for that individual patient.
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10
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Brown SES, Antiel RM, Blinman TA, Shaw S, Neuman MD, Feudtner C. Pediatric Perioperative DNR Orders: A Case Series in a Children's Hospital. J Pain Symptom Manage 2019; 57:971-979. [PMID: 30731168 DOI: 10.1016/j.jpainsymman.2019.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 02/05/2023]
Abstract
CONTEXT Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period are limited. OBJECTIVES To evaluate perioperative management of DNR orders at a tertiary care children's hospital. METHODS We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from February 1, 2016, to August 1, 2017. Using standardized case report forms, we abstracted the following from physician notes: 1) patient/family wishes with respect to the DNR, 2) whether preoperative DNR orders were continued, modified, or suspended during the perioperative period, and 3) whether life-threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision-making in the perioperative period. RESULTS Twenty-three patients aged six days to 17 years had a DNR order in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures and suspended for 15 (51%). Three children (13%) suffered life-threatening events. We identified four time points in the perioperative period where systematic reconsideration should be documented in the medical record, and identified recommended personnel involved and important discussion points at each time point. CONCLUSION Opportunities exist to improve how DNR orders are managed during the perioperative period.
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Affiliation(s)
- Sydney E S Brown
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Ryan M Antiel
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Thane A Blinman
- Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susanna Shaw
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mark D Neuman
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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11
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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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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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13
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Fallat ME, Hardy C, Meyers RL, Besner GE, Davidoff A, Heiss KF, Agarwal R, Tobias J, Brown RE, Guzzetta NA, Honkanen A, Landrigan-Ossar M, Katz AL, Laventhal NT, Macauley RC, Moon MR, Okun AL, Opel DJ, Statter MB. Interpretation of Do Not Attempt Resuscitation Orders for Children Requiring Anesthesia and Surgery. Pediatrics 2018; 141:peds.2018-0598. [PMID: 29686145 DOI: 10.1542/peds.2018-0598] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This clinical report addresses the topic of pre-existing do not attempt resuscitation or limited resuscitation orders for children and adolescents undergoing anesthesia and surgery. Pertinent considerations for the clinician include the rights of children, decision-making by parents or legally approved representatives, the process of informed consent, and the roles of surgeon and anesthesiologist. A process of re-evaluation of the do not attempt resuscitation orders, called "required reconsideration," should be incorporated into the process of informed consent for surgery and anesthesia, distinguishing between goal-directed and procedure-directed approaches. The child's individual needs are best served by allowing the parent or legally approved representative and involved clinicians to consider whether full resuscitation, limitations based on procedures, or limitations based on goals is most appropriate.
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Affiliation(s)
- Mary E. Fallat
- Department of Surgery, University of Louisville, Louisville, Kentucky; and
| | - Courtney Hardy
- Division of Pediatric Anesthesiology, Washington University in St Louis, St Louis, Missouri
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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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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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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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17
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Yu J, Brown D, Kodner IJ, Ray S. Looking beyond the crystal ball: An ethical dilemma in advance directive implementation in multidisciplinary patient care. Surgery 2015; 158:1389-94. [DOI: 10.1016/j.surg.2015.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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18
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Grant SB, Modi PK, Singer EA. Futility and the care of surgical patients: ethical dilemmas. World J Surg 2015; 38:1631-7. [PMID: 24849199 DOI: 10.1007/s00268-014-2592-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Futility has been a contentious topic in medicine for several decades. Surgery in critical or end-of-life situations often raises difficult questions about futility. In this article, we discuss the definition of futility, methods for resolving futility disputes, and some ways to reframe the futility debate to a more fruitful discussion about the goals of care, better communication between surgeon and patient/surrogate, and palliative surgical care. Many definitions of futile therapy have been discussed. The most controversial of these is "qualitative futility" which describes a situation in which the treatment provided is likely to result in an unacceptable quality of life. This is an area of continued controversy because it has been impossible to identify universally held beliefs about acceptable quality of life. Many authors have described methods for resolving futility disputes, including community standards and legalistic multi-step due process protocols. Others, however, have abandoned the concept of futility altogether as an unhelpful term. Reframing the issue of futility as one of inadequate physician-patient communication, these authors have advocated for methods of improving communication and strengthening the patient-physician relationship. Finally, we discuss the utilization of consultants who may be of use in resolving futility disputes: ethics committees, palliative care specialists, pastoral care teams, and dedicated patient advocates. Involving these specialists in a futility conflict can help improve communication and provide invaluable assistance in arriving at the appropriate treatment decision.
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Affiliation(s)
- Scott B Grant
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, 08901, USA
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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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Burkle CM, Swetz KM, Armstrong MH, Keegan MT. Patient and doctor attitudes and beliefs concerning perioperative do not resuscitate orders: anesthesiologists' growing compliance with patient autonomy and self determination guidelines. BMC Anesthesiol 2013; 13:2. [PMID: 23320623 PMCID: PMC3548687 DOI: 10.1186/1471-2253-13-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 11/23/2012] [Indexed: 12/21/2022] Open
Abstract
UNLABELLED BACKGROUND In 1993, the American Society of Anesthesiologists (ASA) published guidelines stating that automatic perioperative suspension of Do Not Resuscitate (DNR) orders conflicts with patients' rights to self-determination. Almost 20 years later, we aimed to explore both patient and doctor views concerning perioperative DNR status. METHODS Five-hundred consecutive patients visiting our preoperative evaluation clinic were surveyed and asked whether they had made decisions regarding resuscitation and to rate their agreement with several statements concerning perioperative resuscitation. Anesthesiologists, surgeons and internists at our tertiary referral institution were also surveyed. They were asked to assess their likelihood of following a hypothetical patient's DNR status and to rate their level of agreement with a series of non-scenario related statements concerning ethical and practical aspects of perioperative resuscitation. RESULTS Over half of patients (57%) agreed that pre-existing DNR requests should be suspended while undergoing a surgical procedure under anesthesia, but 92% believed a discussion between the doctor and patient regarding perioperative resuscitation plans should still occur. Thirty percent of doctors completing the survey believed that DNR orders should automatically be suspended intraoperatively. Anesthesiologists (18%) were significantly less likely to suspend DNR orders than surgeons (38%) or internists (34%) (p < 0.01). CONCLUSIONS Although many patients agree that their DNR orders should be suspended for their operation, they expect a discussion regarding the performance and nature of perioperative resuscitation. In contrast to previous studies, anesthesiologists were least likely to automatically suspend a DNR order.
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Affiliation(s)
- Christopher M Burkle
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Keith M Swetz
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Matthew H Armstrong
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Mark T Keegan
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
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Cardiac resuscitation in the operating room: Reflections on how we can do better. Can J Anaesth 2012; 59:522-6. [DOI: 10.1007/s12630-012-9697-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 03/14/2012] [Indexed: 10/28/2022] Open
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Scott TH, Gavrin JR. Palliative surgery in the do-not-resuscitate patient: ethics and practical suggestions for management. Anesthesiol Clin 2012; 30:1-12. [PMID: 22405428 DOI: 10.1016/j.anclin.2012.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Palliative care in the United States has made tremendous strides in the last decade. One of the most perplexing issues arises when a palliative care patient presents to the operating room with an already existing do-not-resuscitate (DNR) order. This article describes the most common conflicting issues that may arise and provides guidance to surgeons, anesthesiologists, patients, and their primary physicians to reach satisfactory resolution and optimal care. Anesthesia departments should appoint a liaison to surgical and perioperative nursing departments to provide education and create an atmosphere conducive to discussions with palliative care patients about goals of care, including DNR status.
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Affiliation(s)
- Thomas H Scott
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, 19104, USA.
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Do-not-resuscitate orders in evolution: Matching medical interventions with patient goals*. Crit Care Med 2011; 39:1213-4. [DOI: 10.1097/ccm.0b013e31821488b4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
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.
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Affiliation(s)
- Charles G Stack
- Department of Paediatric Anaesthesia and Intensive Care, Sheffield Children's Hospital, Sheffield, UK.
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Anesthesiologist Management of Perioperative Do-Not-Resuscitate Orders: A Simulation-Based Experiment. Simul Healthc 2009; 4:70-6. [DOI: 10.1097/sih.0b013e31819e137b] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Do As We Say, Not As You Do: Using Simulation to Investigate Clinical Behavior in Action. Simul Healthc 2009; 4:67-9. [DOI: 10.1097/sih.0b013e3181a4a412] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Waisel D, Jackson S, Fine P. Should do-not-resuscitate orders be suspended for surgical cases? Curr Opin Anaesthesiol 2007; 16:209-13. [PMID: 17021462 DOI: 10.1097/00001503-200304000-00016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW There are significant misunderstandings about the management of perioperative do-not-resuscitate orders. This paper reviews some of the difficulties generated by the halting acceptance and inconsistent implementation of an ethically appropriate perioperative do-not-resuscitate policy that mandates reconsideration of existing do-not-resuscitate orders. It also offers strategies for empowerment of such a policy. RECENT FINDINGS Recent advances in the ethical practice of anesthesiology have centered on determining and correcting why perioperative do-not-resuscitate policies are poorly accepted, and how to establish a hospital-wide adherence to such policies. Barriers to ethically appropriate application of perioperative do-not-resuscitate orders include differing values and misunderstandings between physicians and their patients - and also between anesthesiologists and other physicians - as well as medicolegal concerns. Policies should be designed and implemented at the level of the healthcare institution, and they must be sufficiently flexible to permit the tailoring of the perioperative do-not-resuscitate order to the autonomous choice of the patient. Such policies should state unambiguously that existing do-not-resuscitate orders are to be reevaluated, delineate responsibilities for reconsidering the do-not-resuscitate order, state available options, define necessary documentation, and list resources for help. SUMMARY A well written perioperative do-not-resuscitate policy is essential for surmounting obstacles to a well functioning perioperative do-not-resuscitate system.
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Affiliation(s)
- David Waisel
- Department of Anesthesia, Harvard Medical School, and Children's Hospital Boston, Boston, Massachusetts, USA
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Abstract
Recent advances in perioperative refusal of resuscitation center on goal-directed orders. Goal-directed orders permit patients to define perioperative resuscitation in terms of outcomes rather than procedures. A typical goal-directed order may state 'The patient desires resuscitative efforts during surgery and in the postoperative care unit only if the adverse events are believed to be both temporary and reversible, in the clinical judgment of the attending anesthesiologists and surgeons.' This review also discusses ways to use the ability to withdraw care as a way of honoring patients' wishes.
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Affiliation(s)
- D B Waisel
- Department of Anesthesia, Children's Hospital, and Department of Anesthesia, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Abstract
Ethical concerns are common in palliative care settings. Rather than provide an exhaustive list of possible ethical problems one may come upon, this article describes areas of concern that are frequently encountered by perioperative health care providers, especially anesthesiologists, in the palliative care arena.
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Affiliation(s)
- Richard A Demme
- Nephrology Division, The Center for Palliative Care and Clinical Ethics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 675, Rochester, NY 14624, USA.
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Affiliation(s)
- Robert D Truog
- Department of Anesthesia, Children's Hospital Boston, and Harvard Medical School, Boston, MA 02115, USA.
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Abstract
This clinical report addresses the topic of preexisting do-not-resuscitate (DNR) orders for children undergoing anesthesia and surgery. Pertinent issues addressed include the rights of children, surrogate decision-making, the process of informed consent, and the roles of surgeons and anesthesiologists. The reevaluation process of DNR orders called "required reconsideration" can be incorporated into the process of informed consent for surgery and anesthesia. Care should be taken to distinguish between goal-directed and procedure-directed approaches to DNR orders. By giving parents or other surrogates and clinicians the option of deciding from among full resuscitation, limitations based on procedures, or limitations based on goals, the child's needs are individualized and better served.
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Abstract
The perioperative care of patients who have diseases of the nervous system provides the setting for challenging ethical issues. In the preoperative period, these issues include obtaining informed consent for surgery and its complications, surrogate decision making for the neurologically incapacitated patient, the use of advance directives for medical care, and the temporary suspension of do-not-resuscitate orders during the perioperative period. During postoperative care, ethical issues include establishing and communicating prognosis in patients who are brain damaged, a trial of therapy when prognosis remains uncertain, surrogate consent and refusal of life-sustaining therapy in the neurologically impaired patient, and the management of brain death.
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Abstract
An iatrogenic arrest is a cardiopulmonary arrest induced by a therapeutic effort. Frequently cardiopulmonary arrests during hemodialysis (HD) are iatrogenic. In this article I consider the question of what to do when a cardiopulmonary arrest occurs during HD in a patient with a do not resuscitate (DNR) order. I consider and reject four arguments to override the DNR order: the principle of nonmaleficence, the efficacy of resuscitation, proximate cause, and physician error. Instead, I argue that respect for patient autonomy and patient goals means that DNR orders must be respected unless there is compelling evidence that overriding the DNR would be consistent with the patient's goals. If such evidence is lacking, the physician has no moral choice but to follow the DNR order literally. As such, nephrologists need better communication with their patients regarding advance care planning and better documentation of their communication once it has occurred.
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Affiliation(s)
- Lainie Friedman Ross
- Department of Pediatrics and MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois 60637, USA.
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Abstract
BACKGROUND In 1976, the first hospital policies on orders not to resuscitate were published in the medical literature. Since that time, the concept has continued to evolve and evoke much debate. Indeed, few initials in medicine today evoke as much symbolism or controversy as the Do-Not-Resuscitate (DNR) order. OBJECTIVE To review the development, implementation, and present standing of the DNR order. DESIGN Review article. MAIN RESULTS The DNR order concept brought an open decision-making framework to the resuscitation decision and did much to put appropriate restraint on the universal application of cardiopulmonary resuscitation for the dying patient. Yet, even today, many of the early concerns remain. CONCLUSIONS After 25 yrs of DNR orders, it remains reasonable to presume consent and attempt resuscitation for people who suffer an unexpected cardiopulmonary arrest or for whom resuscitation may have physiologic effect and for whom no information is available at the time as to their wishes (or those of their surrogate). However, it is not reasonable to continue to rely on such a presumption without promptly and actively seeking to clarify the patient's (or surrogate's) wishes. The DNR order, then, remains an inducement to seek the informed patient's directive.
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Affiliation(s)
- Jeffrey P Burns
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
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Waisel DB, Burns JP, Johnson JA, Hardart GE, Truog RD. Guidelines for perioperative do-not-resuscitate policies. J Clin Anesth 2002; 14:467-73. [PMID: 12393121 DOI: 10.1016/s0952-8180(02)00401-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This paper reviews some of the difficulties in implementing perioperative reevaluation of do-not-resuscitate (DNR) orders and suggests several strategies for perioperative DNR policies. Policies should be written, designed and implemented at the level of the institution, and be sufficiently flexible to permit the tailoring of the perioperative DNR order to the individual patient. Policies should unambiguously state that reevaluation is required, delineate responsibilities for reevaluating the DNR order, state all the available options, define the necessary documentation, and list resources for help.
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Affiliation(s)
- David B Waisel
- Department of Anesthesiology, Bader 3, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Caruso LJ, Gabrielli A, Layon AJ. Perioperative do not resuscitate orders: caring for the dying in the operating room and intensive care unit. J Clin Anesth 2002; 14:401-4. [PMID: 12393105 DOI: 10.1016/s0952-8180(02)00388-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Affiliation(s)
- C C Hug
- Anesthesiology Department, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA 30322, USA
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Truog RD, Waisel DB. Do-not-resuscitate orders: from the ward to the operating room; from procedures to goals. Int Anesthesiol Clin 2002; 39:53-65. [PMID: 11524600 DOI: 10.1097/00004311-200107000-00006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- R D Truog
- Multidisciplinary Intensive Care Unit, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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Abstract
The cancer patient presents special challenges to the anesthesiologist. Cancer may have multiple effects including those due to the primary tumor, metastases, the effects and toxicity of cancer therapy, associated paraneoplastic and physiologic responses to the tumor and the strong psychological responses elicited by cancer. The preoperative evaluation of the cancer patient provides opportunities to understand the patient's medical condition and to plan management. Specific goals of the preoperative assessment include a relevant and complete patient history with emphasis on the cancer, thorough examination of the patient, appropriate diagnostic testing and formation of an anesthetic and perioperative plan. Patient education and reassurance regarding issues of safety, pain control and respect for patient preferences are important goals as well. This review provides the anesthesiologist with both general and specific information important to the systematic and complete preoperative evaluation of the patient with cancer.
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Affiliation(s)
- C A Schmiesing
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California 94305, USA.
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Santos KG, Fallat ME. Surgical and anesthetic decisions for children with terminal illness. Semin Pediatr Surg 2001; 10:237-42. [PMID: 11689998 DOI: 10.1053/spsu.2001.26849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Terminal conditions such as congenital anomalies and cancer are a significant source of infant and childhood mortality. Many terminally ill children are considered for operative procedures each year. These procedures may be palliative or elective, and the prognosis and natural course of the terminal illness play a significant role in determining the appropriateness of the surgical procedure. Providing anesthesia to a terminally ill patient is a complex task requiring an appropriate balance between adequate anesthesia and hemodynamic normality. Some children with a terminal condition will have a standing "Do-Not-Resuscitate" order that should not necessarily be reversed. Surgeons, anesthesiologists, and family members must consider a number of factors when determining the appropriateness of an operation for a dying patient, including the rights of the child.
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Affiliation(s)
- K G Santos
- Division of Pediatric Surgery, Department of Surgery, University of Louisville and Kosair Children's Hospital, Louisville, KY, USA
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Hoehner PJ. Ethical decisions in perioperative elder care. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2000; 18:159-81, vii-viii. [PMID: 10935006 DOI: 10.1016/s0889-8537(05)70155-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Settings involving the extremes of age and illness are the most complex in ethical deliberation and require sound principles that can be clearly applied to individual situations. This article discusses how one's view of the aging process effects clinical decision making. The basic principles of medical ethics (autonomy, beneficence, nonmaleficence, and justice) are discussed along with alternative ethical paradigms that may be more appropriate to the elderly population. Issues such as informed consent, do not resuscitate orders in the operating room, and controversies in end-of-life palliative care specifically impact the role of the anesthesiologist. Anesthesiologists, as medical professionals in a health care team, have a great stake in ethical decision making and the ethics of health care policy.
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Affiliation(s)
- P J Hoehner
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, USA
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