SCCM Resource Library-Patients with Preexisting DNAR Orders: Periprocedural Management in the ICU and OR

Video Transcription

Hello, and welcome to this session. My name is Preeti John, and I'm a surgeon, intensivist, palliative medicine physician and healthcare ethics consultant.  This session is titled Patients with Pre-existing DNAR Orders, Periprocedural Management in the ICU and Operating Room.  National organizations in anesthesia, surgery, pediatrics, and perioperative nursing have published guidelines about ethical management of patients with pre-existing DNAR orders.  However, there is widespread lack of familiarity with these guidelines. These are the society guidelines listed for your reference.  There are a few papers discussing this topic of DNAR patients presenting for procedures and about how they are managed, and a couple of them are listed here.  A survey done in 2013 reported that up to 30% of physicians believed that DNAR orders should automatically be suspended in the perioperative period.  Next, we will discuss some issues as well as the ethical dilemma that arises when patients with DNAR orders present for procedures.  I will use the term DNR, do not resuscitate, and DNAR, do not attempt resuscitation interchangeably during this presentation.  Certain tensions arise when patients who wish to forego CPR present for procedures requiring anesthesia.  There is a general perception that maintaining a DNR order is not feasible during administration of anesthesia.  Goals of care conversations prior to a procedure can be complex and time-consuming. Therefore, DNR orders are often routinely suspended prior to procedures requiring anesthesia.  What are the causes of arrest during a procedure that's being done in the operating room or the ICU?  They could be iatrogenic complications related to the procedure itself or to the anesthesia being administered, and they could be due to errors.  They could arise from patient disease and underlying comorbidities. Iatrogenic complications are potentially reversible with the availability of immediate treatment  by trained clinicians. Some believe that it would be ethically unjustifiable to stand back and do nothing in the context of a periprocedural DNR order.  The basic ethical tenet of non-maleficence would be violated if nothing is done. Resuscitation in the operating room reportedly has a higher chance of success compared to  other locations because of continuous monitoring with immediate availability of trained medical personnel.  However, this reasoning should not be invoked to justify routine suspension of DNR orders in the operating room.  Treatment should be individualized based on goals and not based on probabilities. The patient's perspective is what is most important.  From the patient's perspective, whether or not the arrest is iatrogenic or related to the underlying disease matters little compared with how it might affect their wish to live  with an acceptable quality of life. Discussions about individual definitions of quality of life are very important.  Next, we will discuss periprocedural management of patients who present with DNR orders. The first step is to clarify the existing DNR order.  Cardiac deterioration is distinct from cardiac arrest with loss of pulse, and DNR does not mean do not treat clinical deterioration.  DNR indicates a patient's preference and may be reflective of a general desire to avoid a persistent vegetative state.  DNR is an order not to treat following complete cessation of heart function. Patient's autonomy, right to self-determination, respect for dignity, and truth-telling are  key during the process of informed consent. Conversations must address the ambiguities associated with treatment decisions in the setting of a periprocedural DNR order.  The difficulty in predicting intraoperative complications and postoperative outcomes should be clarified.  Automatic causes for deterioration and the possibility of unexpected events should be addressed.  A patient-centered approach is ethically justifiable and involves having conversations prior to procedures to clarify goals of care.  Automatic suspension of an existing DNR order without any discussion is not ethically justifiable and reflects a more paternalistic approach.  How do we conduct periprocedural required reconsideration conversations? Resuscitation wishes should not be presented as all or none choices.  We should clarify patient wishes by discussing both their goals and the procedures involved. Goal-directed discussions involve discussing what the patient's health care goals are.  And procedure-directed discussions can include discussions about life-sustaining treatments performed during anesthesia.  The options for periprocedural resuscitation are to revoke the DNR order and perform resuscitation  in the event of an arrest, regardless of the circumstances, to retain the DNR order, or to agree on limited DNR order based on the procedures involved or based on the goals or both.  Procedure-directed discussions can include discussions about life-sustaining treatments, which are medical interventions used to sustain life, including resuscitation.  These treatments can prolong the life of a patient who would otherwise be expected to die without these treatments.  A levels-of-care approach that groups specific life-sustaining treatments into categories may be easier to grasp for both professionals as well as patients.  Physicians with patients should clarify with them that DNR indicates an order not to have any life-sustaining treatments instituted following cardiopulmonary arrest.  Here is a table discussing the levels-of-care approach when having a procedure-directed discussion.  Level 1 involves routine life-sustaining treatments that are administered during anesthesia. Level 2 indicates treatments required during clinical deterioration.  And level 3 indicates those treatments that are only required during cardiopulmonary arrest, such as chest compressions and defibrillation.  Procedure-directed discussions should include the following questions. What would the patient's definition of a successful resuscitation be?  This depends on the patient's goals and preferences and his or her perspectives about quality of life.  Would success be defined merely by biologic existence and the return of vital signs with continued dependence on life-sustaining treatments?  How long would this be acceptable to the patient? The potential need for specific life-sustaining treatments to be continued after the procedure  should be discussed, and a time-limited trial of life-sustaining treatments should also be discussed to get the patient's perspectives.  Specific reconsideration discussions involve shared decision-making. If the DNR order is temporarily revoked during the procedure, when will it be resumed?  When will the effects of anesthesia wear off, and when does the postoperative period end? This depends on the procedure and the type of anesthesia.  Required reconsideration conversations are beneficial, but they do have challenges. Eliciting and accurately documenting patient wishes prior to procedures will help avoid  confusion and conflict if complications arise. These conversations can be challenging and time-consuming.  The significant time it takes to engage patients in conversations related to advanced care planning has been recognized as a significant barrier.  Palliative procedures can be done in the ICU or the operating room. They are procedures done with the primary intent to improve a patient's quality of  life by relieving suffering secondary to symptoms of advanced disease. The outcome measure is quality of life and not survival.  We have an even greater obligation to conduct required reconsideration conversations for patients undergoing palliative procedures.  With regard to procedures done in the operating room, surgical buy-in is an informal contractual  relationship between the surgeon and the patient, and the traditional concept implies that patients  will accept any treatments necessary for their survival in the perioperative period. However, when patients are probed with questions to clarify their wishes, they often indicate  their desire to limit treatments in certain scenarios, despite presumptions by the surgeon about pursuing aggressive care in the postoperative period.  Appropriateness of treatment refusal, blood transfusion, and cardiopulmonary resuscitation are both examples of life-sustaining treatments.  Institutions have adopted policies that allow the informed Jehovah's Witness patient to refuse blood transfusion and risk perioperative death.  In refusing blood transfusion or CPR, both the Jehovah's Witness patient and the DNR patient  accept that intraoperative death is a possible consequence of their treatment refusal.  Documentation of periprocedural conversations is key.  Health systems should incorporate best practice into the electronic medical record.  The Veterans Health Administration is America's largest integrated healthcare system.  The electronic medical record system within the VA has a life-sustaining treatment template  note to document patient goals of care.  When wishes to limit treatment are documented, orders are automatically generated.  Documentation is in a standard location, easily accessible to all providers in the inpatient and outpatient setting.  As the population ages, more patients with life-limiting conditions and pre-existing DNR orders are likely to present to the ICU, the operating room, or the procedural suite.  Automatic discontinuation of DNR orders is a paternalistic approach and is not ethically appropriate.  Each patient has unique circumstances depending on the type and indications for the surgical procedure and the different types of anesthesia administered.  Multidisciplinary required reconsideration conversations addressing goals of care and explaining life-sustaining treatments should be conducted and documented prior to procedures  to optimize goal-concordant care.  Thank you for your attention.

Video Summary

In this session, titled "Patients with Pre-existing DNAR Orders, Periprocedural Management in the ICU and Operating Room," Dr. Preeti John discusses the ethical management of patients with Do Not Attempt Resuscitation (DNAR) orders. Many healthcare providers are unfamiliar with guidelines published by national organizations regarding these patients. The speaker addresses the ethical dilemma that arises when DNAR patients present for procedures, emphasizing the importance of individualizing treatment based on the patient's goals. The session also covers the periprocedural management of these patients, including the need for clarification of the existing DNAR order and open discussions about the patient's goals of care. Ultimately, the goal is to provide goal-concordant care and optimize patient outcomes in line with their wishes.

Asset Subtitle

Ethics End of Life, 2022

Asset Caption

There is ongoing confusion about appropriate management of patients with preexisting do-not-resuscitate (DNR) orders who present for procedures to the ICU, procedural suites, and operating room. Does the order to limit resuscitation need to be revoked before the procedure? Is it possible to perform procedures while the DNR order is retained? Four societies have published guidelines that have been in place for more than 15 years, yet there is still debate about ethical management of such patients. As the population ages, more intensivists, anesthesiologists, and clinicians who perform invasive procedures will encounter such situations and will need to be aware of appropriate management. Clinicians should be comfortable conducting appropriate discussions. In the context of the COVID-19 pandemic, communication challenges have made discussions about this topic even more challenging. Speakers will present challenges faced by anesthesiologists, surgeons, intensivists, and nurses and discuss what is ethically appropriate in various scenarios.

Meta Tag

Content Type Presentation

Knowledge Area Ethics End of Life

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Ethics and End of Life

Tag Medical Legal Issues

Tag Advance Directives

Year 2022

Keywords

DNAR orders

ethical management

periprocedural management

patient's goals of care

goal-concordant care

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