SCCM Resource Library-Periprocedural Management of Patients With a DNAR Order: Challenges Faced by Anesthesiologists

Video Transcription

Thank you for coming to this session at the Society of Critical Care Medicine Congress. This is a great topic, and I'm thrilled to be able to discuss it with you.  Preparatory procedural management of patients with a do not attempt to resuscitate order, challenges faced by anesthesiologists. My name is Rebecca Oslikson.  I'm a critical care anesthesiologist and palliative care physician and researcher at Stanford University.  And I'm also the division chief for critical care at the Stanford University Medical Center.  So objectives for today's talk, we're going to spend the whole time talking about perioperative management for patients with treatment limitations.  So this is the population we're going to be discussing this entire time. We're first going to talk through some definitions and some key ethical principles, particularly  the use of default options for medical decisions, and specifically thinking about default options in this circumstance of cardiac resuscitation.  We're going to talk a little bit about perioperative resuscitation. Let's dive into some data, as well as look at the current American Society of Anesthesiologists guidelines.  And then we're going to finish with truly an innovative and data informed approach, really a different way to start thinking about this problem.  So I really have to give credit to these authors and this article. This article came out in fall 2021.  This really is describing this new approach for how we might think about do not to attempt resuscitate orders in the perioperative period.  So full kudos to these authors and please refer to this article. I highly recommend it. So let's talk a little bit about default options because we need to really understand what  they are to really understand this topic. So default options, that's an event or condition that is enacted if nothing's chosen. So if you choose nothing, this is what will happen.  It's really a privileged option because it's going to happen even if you choose it or don't. So default options are a privileged status and they really, autonomy is lost when people  are unaware of this decision. So if you don't know if there's even a decision to be made and the default option happens, you've lost autonomy. We'll talk about that a little more.  So the good thing about default options is they can influence certain decisions without restricting choice.  People can still say, I don't want the default option, I'm going to do something else.  But by thoughtfully choosing the default option that is there, we can influence better healthcare quality or certain improvements in outcomes.  And you can get some folks who say, I don't want any default options. Everything should be chosen.  And that's not really possible, particularly when you think about say cardiac resuscitation, you have to have a default option.  And so in that case, you really need to think about of all the default options, which is the most justifiable for this circumstance and for this particular population.  And we use default options all the time in medicine. Please look at this article by Halpern et al over a decade old, and specifically looking  at default policies that are pretty common in medical care and that improve healthcare quality.  And you can see here just in intensive care units, default options to use the ARDS lung protective ventilation settings, default options to have the head of bed at 30 degrees or 45  default options to introduce a sedation vacation or a sedation cessation at a certain point every few days. These are all default options that we use on a pretty regular basis.  So there's some related ethical principles at play here. So first off autonomy, everybody has the right to make decisions about the treatments, which  treatments you want, which treatments you don't. You also have the ethical principle of best interests or beneficence that the options  that are there really should be in the best interest for the persons that are affected. And then freedom of choice. You can make a choice.  You can have all these different options, be informed of the different options and choose between them. So those are the ethical principles that are really at play here.  Now when we think about these ethical principles in the circumstance of default options.  So autonomy, default options, as I've already hinted, involves some potential loss of autonomy.  If you don't know there's a decision being made and a certain circumstance happens through the default option, you've lost the autonomy to actually make that decision.  Best interest. So specifically with default options, you need to think about if this is the default  option I'm choosing, is it of the best interest for the most people who will be affected by it? And then freedom of choice.  People can opt out, but if people don't even know that there is a decision to be made, they may not know that there are options or the ability to opt out.  Now let's think about these ethical principles and default options specifically in perioperative CPR. So autonomy, just not possible.  You can't ask somebody essentially when they're dead, what do you want? Do you want us to do CPR or not? So this is a circumstance where you need a default option. So best interest.  What's in the best interest for the patient? And it can vary based on patient goals, pre-existing medical conditions.  We're going to actually spend a lot of time on this because this is where the truly innovative approach gets layered in. And then freedom of choice.  There are multiple potential options for perioperative CPR, and these are what I describe when I'm talking through these options with patients and their family members.  So you can have somebody who comes in with some sort of treatment limitation before a procedure. They can revert back and be full code.  They can have some sort of limited code or under certain circumstances, certain treatment limitations, but not others.  Or they could go in essentially with the full do not attempt resuscitation, no code in the perioperative period. Okay. So we've done definitions. We've done some ethical principles.  Let's dive into data. Let's really think about perioperative cardiac resuscitation.  So the common lore, what I certainly was raised with is that intraoperative cardiac resuscitation, those outcomes are way better than non-operative ones. So let's look at the data.  So, and you can see, I've given you multiple references here if you want to dive in as well. So incidents of perioperative code. So that's one to 30 in 100,000.  These are rare events. Very rare that it happens. When they do happen, it's related to anesthesia about 70% of the time, not say something that  was intrinsic to the patient, but something that was due to what we as anesthesiologists  would be giving to keep people safe and anesthetized during surgery and survival or return of systemic circulation happens and varies by the study 42 to 71% of the time.  So you're going, well, hey, 42 to 71% of the time, that's pretty good. Well, that's ROSC. That's ROSC in the OR.  Let's compare that out of hospital, 30 day survival from a cardiac arrest is only 9.2%. So already you're saying, oh, 42 to 71%. That sounds great. Definitely.  Perioperative cardiac resuscitation is way better and better outcomes than out of hospital cardiac resuscitation. Let's dive in and look deeper.  So there's actually some strong predictors of worst 30 day mortality. So we're not talking about ROSC. We're talking about, are you alive 30 days after you've coded?  So the patient's ASA status is greatly predictive. So if somebody is an ASA 4, they have an 11 fold increase to being dead at 30 days after  a intraoperative perioperative cardiac arrest. And if they're ASA 5, it's 32 fold increase. So the mortality goes way up when folks are far sicker by ASA status.  Age also factors in. For individuals greater than 85 years old, survival to discharge only 14%, if they have a perioperative cardiac arrest.  So if you are a significantly older adult, greater than 85 years old, and you code in the perioperative period, not as likely you're going to survive to discharge.  And how about folks when they come in with impaired functional status? So if people have absolutely no impaired functional status, likelihood of survival to discharge  if you have a perioperative cardiac arrest, 25%. If they have partially impaired functional status, 15%, and if they are totally impaired  in functional status, so not independent in any of their ADLs or IADLs, survival to discharge is only 11%.  So you can see, these are actually more nuanced data than we're often taught initially or what's thought to be common lore.  So what does the ASA, the American Society of Anesthesiologists say we should do when  going for a procedure and they have a do not attempt resuscitation order, they have some sort of treatment limitation, what are we supposed to do?  So this is the current timeline, this is the current flowchart we're supposed to use. So they present with some sort of treatment limitation.  If they do not have one, then just go, whole code, no questions asked. If they do have some sort of treatment limitation, okay, you revisit it. It's the required reconsideration.  If you talk through this person, what do you want to do in the perioperative period? There are actually two things you need to figure out.  First, are they going to change their code status or not? So that's the first thing. And then if they do change their code status, when does it revert back?  If they change, say, from do not attempt resuscitation to full code, then when does it go back to do not attempt resuscitation? Is it in the PACU? Is it three days post-op?  We need to discuss that and agree on that beforehand. So that's what we are currently supposed to be doing. Well, how well do we do it?  There's not a lot of data, but we do have some. This is a study from Rich Ehrman's group at the Partners Healthcare System in Boston.  They did a retrospective observational study of surgery for a venting gastrostomy, a venting gastrostomy often done for folks who have terminal cancer, who have a malignant bowel  obstruction. So it's typically a group where you have a higher likelihood of folks who have had discussions  about what they want and don't want and where they might have a treatment limitation. So in their database, they went back and looked and they had 53 patients who had received  surgery for a venting gastrostomy. Of those 53 patients, 23 of them, 43% did have a code status limitation before they went to the OR. So what happened to these folks?  How well did they follow? How well were the American Society of Anesthesiologists flowchart followed? So let's break this down. It's a little complicated.  So first off, there was a group where the code status was discussed and it was not changed. So if they came DNAR, they stayed DNAR. Only two people, but that's two.  Then there were 18 people or 78% where it was never discussed at all. So this is not following guidelines. All of these patients are supposed to have their code status discussed.  And so 78% was never, no record at all in, no documentation at all in the medical record that it was discussed. Then we've got three where it was discussed, then what happened?  So we have three, and then one of them, it was discussed. Not only that it was going to be changed, but they also agreed on when it would go back to what it was before.  And two where it was discussed, but it couldn't find any documentation of when it would go back to what it was prior to surgery.  So taking it all together, only three of these patients, 13% had care that was consistent with what's recommended as far as the required reconsideration by the ASA.  And 20, 87% did not have their treatment follow those guidelines. I don't know about you, but this is consistent with my own personal anecdotal experience  where even when required reconsideration is supposed to happen, it often doesn't for a variety of different cultural and pragmatic reasons.  So this is what we're doing, but at least per the data we have, we're not doing it that well. So this is where the group that I mentioned before really proposed a better option.  So this is what they are proposing. Notice it does not come with the DNAR requirement before folks enter the flow chart.  You enter the flow chart if you are a patient who is 75 or older, and this is based on those  data that the older you get and the more functional limitations you have, the less likely being  coded in the perioperative period is likely to result in you leaving the hospital alive or having a good functional outcome.  So you start at age 75 and then you go through a vulnerability screen. Is the patient greater than 85 years old, ASA status 4 or above, or is there any documentation  or evidence of significant frailty or functional impairment? If all of those are negative, so between the ages of 75 and 85, ASA 1, 2, or 3, no frailty,  then they proceed as a full code and nothing's changed. Yet if any of those circumstances are present, then it clicks into a conversation about code  status and really what's supposed to be a thoughtful discussion about risks and benefits  of CPR, particularly given that person's limitations, their risk factors going in, as far as what they would consider to be a worst possible outcome.  There are certainly patients and family members who feel significant functional limitations or a long hospitalization is a worse outcome even than death.  And so it really gives the opportunity to structure the code status and the approach to the operating room period based on what the patient's goals are. So that's that.  And note that it looks very similar. This is the American College of Surgeons Geriatric Surgery Verification QI Framework.  So this was also proposed recently, and it has a similar idea where patients at the age of 75, they rather than just immediately going to surgery, full code status, regardless of  whatever they may come in with limitations or coexisting illnesses, but instead there's another vulnerability screen. You can see age is in there again.  And also too, this isn't just what's your code status. This is, are you going to go to the ICU afterwards?  Because if any of these things are present, these patients are to be sent to the ICU because they are at such high risk for having a perioperative morbid or mortal event.  And with this too, there's discussion of life-sustaining interventions, including resuscitation. So very similar to what the ASA presents, even in more detail.  So it's not just this group kind of pushing the ASA to think a little bit more of how  we approach these patients, but also our colleagues in surgery recommending that we have similar conversations. So this is kind of bringing us all to a conclusion.  CPR inherently requires default options.  There's no way to have a system where you do cardiopulmonary resuscitation and you don't have some sort of default option.  You can't ask somebody when they're dead already what they want, and it's not practical to ask their family either. So you need a default option.  Note that perioperative resuscitation outcomes, they're particularly bad for some patients.  That lure of perioperative resuscitation goes well, far better than out of hospital arrest. You know, we should always do it.  That's not necessarily true, particularly for individuals that are ASA 4 and 5, individuals 85 years and older, and or individuals with some sort of functional limitation.  The current default of required reconsideration, implementation's not so great, and the default option of full codes may not really be a best interest for some high-risk patients.  So maybe it's really time to consider different and more nuanced approaches. The American College of Surgeons and their geriatric group is pushing for this.  I already showed you the Allen et al. article, which also pushes for the ASA to think about this differently.  And I would encourage you in your critical care practice to really think about these patients in a different way.  Too often I hear folks say, well, you know, our practice is just full code for any perioperative  or peri-procedural period, and then they can go back to a treatment limitation or, you know, even the 85-year-old is functionally 65, and so we shouldn't have this conversation.  And I would kind of encourage that that's not necessarily practicing in a data-informed fashion.  These outcomes for these individuals are different, and it's worth a good conversation. So thank you so much.  I really welcome you spending a little bit of time with not only me, but with everybody else at this session.  And I welcome any questions after this session, and feel free to reach out to me by email. It's just my last name, oslikson, at stanford.edu. Thank you so much.

Video Summary

In this video, Dr. Rebecca Oslikson, a critical care anesthesiologist and palliative care physician at Stanford University, discusses the challenges faced by anesthesiologists in managing patients with do not attempt to resuscitate (DNAR) orders in the perioperative period. She explains the concept of default options, which are enacted when no choice is made, and their impact on autonomy and healthcare quality. Dr. Oslikson reviews data on perioperative cardiac resuscitation outcomes and highlights the higher mortality rates for older patients and those with impaired functional status. She critiques the current American Society of Anesthesiologists guidelines, which recommend required reconsideration of code status but are not consistently followed in practice. To address these issues, she presents a new approach proposed by a group of authors that focuses on thoughtful discussions about code status based on individual patient goals and risks. She also mentions that the American College of Surgeons has recommended similar conversations in their guidelines for geriatric surgery. Dr. Oslikson emphasizes the importance of considering these patients in a more nuanced way and invites further discussion and inquiry.

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 Advanced

Membership Level Select

Tag Medical Legal Issues

Tag Ethics and End of Life

Tag Advance Directives

Year 2022

Keywords

anesthesiologists

DNAR orders

perioperative period

default options

mortality rates

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.