Transcript Slide 1

DNR/DNI in the OR
Where are we now?
Milla Muller, C.R.N.A., MSN
Massachusetts General Hospital
Department of Anesthesia, Critical Care and Pain Management
Objectives
Review the history of patient autonomy and
informed consent
Understand the expectations of the patients
and family
Review the ethical, medicolegal and regulatory
issues related to the care of patients with
active DNR orders.
Foster discussion about optimal care practices
of DNR patients perioperatively
Content
 What is the dilemma related to the care of patients
with active DNR orders perioperatively?
 What are the current perspectives on end of life
care and perioperative code status?
 How is this issue effecting our operating rooms?
 What are the guidelines supported by professional
anesthesia and surgical organizations?
 What constitutes informed consent during code
discussion?
 How can this discussion be better optimized and
where do we go from here?
Case
 70 yo male
 Presenting for an angiogram
 PMH of PVD, MI, HTN, COPD
 DNR- code status not addressed prior to procedure
 MAC
 Pt has an allergic reaction to IV contrast
 Requires CPR and undergoes prolonged period of
rehabilitation
 Sues the hospital while in rehab for “wrongful
prolongation of life”
Case
 73 yo male presents for a left BKA
 PMH : severe CAD, PVD, stroke
 Active DNR order; no intraoperative CPR
 Spinal anesthetic and sedation
 After 20 minutes, the patient complains of weakness in
his arms, and difficulty breathing. Within 3 minutes, his
blood pressure and heart rate fall, and he abruptly
arrests.
In every house
where I come I
will enter only
for the good of
my patients,
keeping myself
far from all
intentional illdoing and…
Ethical Issues
HISTORY
 1960: Development of CPR by closed-chest massage
 1974: AMA recognizes that DNR wishes should be
documented and communicated to all attending staff
 1976: First DNR case to be litigated
 1983: CPR became the standard; becoming the only treatment
that required and order to be withheld.
 1988 : JCAHO requires hospitals to implement policies on
resuscitative efforts and end of life care.
 1990 Patient Determination Act
 1990: AANA publishes guidelines supporting
“required reconsideration” of DNR orders
 1993: ASA publishes guidelines against automatic
suspension of DNR orders
 1995: "Physician Orders for Life-Sustaining Treatment"
(POLST) form released in Oregon
 2008: Massachusetts Acts of 2008 mandates a "POLST
Paradigm" demonstration program
 February 2010: Implementation of “MOLST” and use of
Comfort Care/DNR form for out of hospital arrests.
The aging population and its impact on
the surgery workforce.
Etzioni DA; Liu JH; Maggard MA; Ko CY
© 2003 Lippincott Williams & Wilkins, Inc.
Annals of Surgery. 238(2):170-7, 2003 Au 2
g. (1)
Downloaded from http://www.mass.gov/eohhs/provider/guidelinesresources/clinical-treatment/comfort-care/public-health-oems-comfortcare-verification.html December 28, 2011
(7)
The Confusion
 Does routine anesthetic management inherently imply
resuscitation?
 Does automatic suspension of DNR/DNI code status
constitute breach of duty or negligence on the part of
the anesthetist?
 Who has the perioperative code discussion and makes
the final decision?
 Do anesthesia providers have the right not to take care
of a patient with an active DNR order?
 What constitutes liability in failing to uphold a DNR
order and/or provide informed consent?
Anesthesia is the partial or complete loss of sensation, with or without loss of
consciousness as a result of disease, injury or the use of a drug or gas……
Patient Demographics
 10-15% of hospitalized patients have a DNR order entered
in house (2)(17)
 8-10 % of patients requiring surgery have DNR/DNI orders
(2)(8)
with a mean age is approximately 68-79 (5)
 In hospital mortality rates for DNR/DNI patients are
approximately 3-4x the mortality rate in non-DNR patients (4)
 DNR/DNI patients have a 30-50% in hospital mortality rate
and an 80% mortality within 2 years of discharge (3) (4)
 The percentage of the patient population with DNR/DNI
orders is increasing.
DNR in the operating room
 Procedures for DNR patients are usually palliative
in nature
 Surgical risks are weighed against the possibility of
improving one’s quality of life
 DNR patients have a significantly higher mortality
rate within 30 days surgery
(2)(5)
 Active DNR order: an independent predictor of
postoperative mortality vs. sign of confounding
comorbidity
From:
High Mortality in Surgical Patients With Do-Not-Resuscitate Orders: Analysis of 8256
Patients
Arch Surg. 2011;146(8):922-928. doi:10.1001/archsurg.2011.69
Figure Legend:
Figure 1. Unadjusted mortality rates of do-not-resuscitate (DNR) and non-DNR patients by procedure, American
College of Surgeons National Surgical Quality Improvement Program (2005-2008). Procedures were done in 2%
or more of study sample (decreasing frequency from left to right of x-axis). (5)
Date of download: 1/6/2013
Copyright © 2012 American Medical
Association. All rights reserved.
The DNR/DNI code status in the
OR: Automatically Suspended?
 The nature of the anesthetic requires airway manipulation and
inherently implies that the patient will be intubated.
 Being under anesthesia implies the need to be resuscitated
since it causes cardiopulmonary depression (21).
 During a critical event it is difficult to decide if the patient’s
arrest is due to iatrogenic or intrinsic causes related to the
patient’s comorbidities.
 Assuming that the proximate cause (anesthesia) caused the
arrest is the safest alternative (15)
 Therefore, resuscitation of an arrest due to iatrogenic causes
does not fall within the scope of the DNR / DNI order.
Surveys of Anesthesiologists
and Surgeons
 Anesthesiologists assume DNR/DNI 50-60% of the time
(11) 0
 Surgeons assume suspension 40% of the time
(11)
 Recent national survey of cardiothoracic, neurosurgical
and vascular surgeons reveals that over 50% would
refuse or be reluctant to operate on a patient with a
preoperative request to limit life supporting treatments (2
6)
 Both groups are more likely to override DNR orders if the
cause of the arrest was iatrogenic or due to “physician
error” .
CRNA Perspectives
 50% are unsure of departmental policies or if a
policy exists
 Approximately 67% indicate a policy of automatic
DNR suspension
 20% have a policy of reconsideration
 54% favored a policy or reviewing DNR orders
 More than 90% indicated that they would discuss
DNR orders with the patient before surgery
 40% would resuscitate a patient with a DNR order
Legal Risks
The right of a competent adult patient to refuse
medical treatment has its origins in the
constitutional right of privacy….and is in the
“penumbra” of rights guaranteed by the Fifth and
Ninth Amendments to the United States
Constitution.
-California Appellate Court, Bartling et al v The Superior Court of Los Angeles
County, 1984
Negligence
 Plaintiff must prove that the health care provider
breached the standard of care
 Requires proofs of duty, breach of duty, causation
and damages
Battery
 Plaintiff must prove intentional and nonconsensual
physical contact.
 In some states, must prove resulting damages.
Informed Consent
 No procedure may be performed on a patient
without his or her consent
 Consent is founded in the 4th and 14th
Amendments to the Constitution and upheld by
Common Law
 Right to Privacy and Self Determination
 Requires full disclosure of risks
 Procedures performed without consent or against
expressed wishes of the patient constitute
intentional tort of battery
Sources of health information as reported by elderly patients.
Adams D H , Snedden D P J Am Osteopath Assoc
2006;106:402-404
Published by American Osteopathic Association
Perceived chances of surviving cardiopulmonary resuscitation to discharge.
Adams D H , Sweden D P J Am Osteopath Assoc
2006;106:402-404 (9)
Published by American Osteopathic Association
CPR Outcomes
 Outcome of intraoperative CPR is significantly better for patients
undergoing elective rather than emergent procedures (23)
 Long term outcome data is variable: 30-40% rate of functional
impairment and up to a 70% degree of neurological impairment (29)
 Factors associated with poor prognosis: pre-op sepsis and
hypotension, age>60, ASA class III or greater, pO2 <50, prolonged
resuscitation >10 min , pneumonia, Class III CHF, metastatic
cancer. (19)(3)
 Most patients discharged after cardiac arrest experience a
reversible event and have no major underlying comorbidities (18)
CPR Outcomes
 In hospital survival rate : 34-40%
hospital discharge rate of 14-17%
(19) (23)
 Intraoperative cardiac arrest averages: 4-8/10,000 (22)(23 (30))
 Anesthesia related intraoperative cardiac arrest : 1/10,000
(30)
 Intraoperative successful resuscitation rates considerably higher
>60 %
(23)(8)
Witnessed arrest
Iatrogenic Causes
Often of respiratory etiology
Patient Perspectives
Survey of patients > 60 yo
 Prior to knowing survival statistics, 41% wanted CPR
 After knowing the probability of survival, 17% opted for
CPR
Asked about arrest with a chronic illness when life
expectancy was < 1 yr
 11% wanted CPR
 After learning the probability of survival only 5% wanted
CPR
Informed Consent and the DNR
Discussion
Was the patient competent?
Was there full disclosure?
Was there understanding?
Was there mutual decision making?
“Is there a chance that you will die under the anesthetic? Well, that is the killer
question “
AANA Position
 The tradition of automatic rescission of an advance
directive must be replaced with one of “required
reconsideration”
 This involves a discussion with the patient or
his/her health care proxy
 The discussion should be documented in the
patient’s chart, including the summary of the
agreed plan.
 If the CRNA is unwilling to honor the patient’s
choices, then transfer of care should be facilitated.
ASA Guidelines
ACS Statement
Policies automatically suspending DNR
orders prior to procedures involving
anesthetic care many not sufficiently
address a patient’s right to self
determination.
Recognizes that policies leading to either
automatic enforcement OR cancellation of
DNR orders may not address the patient’s
right to self determination
Provides three alternatives:
A. Full attempt at resuscitation
B. Limited attempt at Resuscitation
Defined with Respect to Specific
Procedures
C. Limited Attempt at Resuscitation
Defined with Regard to Patient’s
Goals and Values
Recognizes potentially correctable risks of
intraoperative cardiac arrest.
Any changes to directive should be
documented in medical record and
plans for postop care should indicate if
of when the original, pre-existent
directive will be reinstated
Discussions between the patient and
physicians responsible for patient’s care
should address new risks and approach to life
threatening problems should be documented.
Concurrence on these issues by the
primary care physician or the surgeon
and anesthesiologist is desirable.
Recognizes surgeon’s responsibility in guiding
patients with decision making process
Best approach is “required reconsideration”
addressing new risks.
Preoperative Code Discussion
 Procedure Driven: Discussion related to which specific
procedures patients would want during a cardiac arrest
Pros: Decreases Ambiguity
Cons: Limited flexibility
 Goal Driven: Discussion requires an understanding of patient’s
goals
Pros: Allows anesthetists discretion in choosing the most appropriate
intervention based on the clinical context and patient’s wishes
Cons: CPR outcomes are not easy to predict. Under time constraints
understanding patient wishes is not always feasible. (2)(17(14)
Plan Based on Individual Goals of Care
Procedure Driven Discussion
• Chest compressions
• Defibrillation or electrical cardioversion
• Implantable cardiac defibrillators
• VAD devices
• Endotracheal intubation
• Mechanical intubation
• Non-invasive ventilatory support
• Vasopressors
• Monitoring devices, etc.
Goal Driven Discussion
 Requires a discussion between the anesthetist,
patient and often family
 Is driven by goals and likely outcomes of
intervention
 Is often a multidisciplinary approach
Documentation
(14)
 Document if there is a change in code status
 Document that risks vs. benefits have been addressed.
 Progress note signed by attending physician
 Document patient’s, family’s and surrogates goals and
wishes (14)
 Document that the plan has been communicated to all
members of care team.
 Time limits: when should the order be reinstated
 Avoid ambiguity: what and what would not be done
during a cardiac arrest (17)
Practices for Consideration
Understand patient wishes and expectations of their
clinical outcome
Provide full disclosure and informed consent
Appreciate your own ethical and practice standards
and understand department policies
Foster communication across specialties
DOCUMENT!
Practices for Consideration
 Use of DNR directives is increasing
 Patients need to understand the implications of a
perioperative DNR order and we need to
understand their goals and wishes
 Discussion of perioperative code status requires
multidisciplinary collaboration and documentation
 Automatic suspension or continuation of code
status disregards patient autonomy and prevents
anesthetists from delivering quality care at the end
of life.
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