Addressing Perioperative Do-Not-Resuscitate Orders: An Overlooked Necessity

Copyright 2019. Adam Clark Smith. All Rights Reserved. Disclosure Statement AANA Annual Congress 2019 Adam Clark Smith

. I have no financial relationships with any commercial interest related to the content of this activity.

. I will not discuss off-label use during my presentation. Learner Outcomes . List three possible outcomes of a patient’s advanced directives for the perioperative period, based on the AANA guideline "Reconsideration of Advance Directives: Practice Guidelines and Considerations for Policy Development.”

. Identify three barriers CRNAs encounter when addressing and implementing perioperative Do-Not-Resuscitate (DNR) orders.

. Explain strategies CRNAs can utilize when communicating to patients with advance directives. Outline . Advance Directives and DNR order . Guidelines: Reconsideration of Advance Directives . In-Hospital Cardiac Arrest and Perioperative Cardiac Arrest . Informed Consent/Preoperative Discussion . Barriers to Addressing and Implementing DNR orders . Case reports . Systems in Practice Ethical Dilemma . “The practice of anesthesia is inseparable from the process of intraoperative resuscitation.” Franklin Rothenberg

. Automatically suspend DNR for perioperative period?

. Complexity and significance of the DNR order in the perioperative period

. Policies on how to handle perioperative DNR orders?

(Byrne et al., 2014; Rothenberg, 2011) U.S. Population 65+ Definitions Advance Directive (AD): Legally-binding; allows patients to provide direction about the healthcare they wish to receive if incapacitated

. Health Care Power of Attorney (HCPOA): Appoints a legal decision maker to make healthcare decisions on patient’s behalf

. Living Will: States whether or not you desire life-prolonging measures if 1) your condition is uncurable, 2) you are unconscious, or 3) you have advanced dementia

(AANA 2015) HCPOA

1. Designation of Health Care Agent.

I, ______, being of sound mind, hereby appoint the following person(s) to serve as my health care agent(s) to act for me and in my name (in any way I could act in person) to make health care decisions for me as authorized in this document. My designated health care agent(s) shall serve alone, in the order named.

A. Name: ______Home Telephone: ______Home Address: ______Work Telephone: ______Cellular Telephone: ______

B. Name: ______Home Telephone: ______Home Address: ______Work Telephone: ______Cellular Telephone: ______

C. Name: ______Home Telephone: ______Home Address: ______Work Telephone: ______Cellular Telephone: ______

(NC Advance Health Care Directive Registry, 2007) Living Will

(NC Advance Health Care Directive Registry, 2007) Physician Orders for Life-Sustaining Treatment (POLST) Form

. Portable medical order form of patients’ treatment wishes . Complements an Advance Directive; it does not replace it . Identifies CPR / DNR preferences . Cannot be used to identify a HCPOA . aka MOLST, MOST or POST . https://polst.org/ POLST Form (California)

https://capolst.org/ MOST Form (North Carolina)

http://www.ncmedsoc.org/non_members/public_ resources/MOSTform_sample.pdf Voluntary Non-Opioid Advance Directive (West Virginia)

[MA, MI, LA, PA, CT, AK, others]

https://dhhr.wv.gov/Office-of-Drug-Control- Policy/Documents/WV%20NonOpioid%20Directive.pdf Let’s talk about it

https://i.redd.it/prushkgdo9mz.jpg Do Not Resuscitate Order

. Founded on ethical principle of respect for individual autonomy and the legal doctrine of informed consent

. Applies only in event of a cardiopulmonary arrest

. Cardiopulmonary resuscitation (CPR) will not be initiated at the time of arrest – CPR may include: intubation; assisted ventilation; external cardiac compression; electrical defibrillation of heart; drug therapy

(AANA, 2015) DNR – Do Not Round? . Does not signify an end of treatment of any current medical condition

. Does not exclude someone from treatment in the ICU, chemotherapy, dialysis, surgery, or even intubation

. Many choose to forego interventions, such as CPR, and their possible benefits because of the burdens associated with them

. 15% of surgical patients have some form of preexisting DNR

(Ewanchuk et al., 2006; Rothenberg, 2011; Waisel et al., 2003) Patient Self Determination Act (PSDA) of 1991

Healthcare institutions must:

. Inform patients of their right to consent to or refuse medical care

. Provide admitted patients with advanced directive (AD) information

. Ask if patient has an AD & document that in their medical record

. Educate their staff and community about ADs

. Never discriminate against patients if AD or not

Patient Self-Determination Act of 1990, Pub. L. No. 101-508, 105 Stat. 1388-44-115 Routine suspension of DNR for surgery • Violates patient autonomy • Violates Patient Self-Determination Act

Individualized, rather than automatic, suspension Robert Truog, MD Professor of Medical Ethics, Anesthesiology & Pediatrics Director of the Center for Bioethics (Jackson, 2015) Harvard Medical School (AANA, 2015) Full suspension All provisions of the advance directive are suspended during anesthesia and the procedure for a specified period of time.

Partial suspension or modification Specific provisions of the advance directive are suspended or modified during anesthesia and the procedure for a specified period of time.

No suspension The provisions of the advance directive remain active during anesthesia and the procedure.

(AANA, 2015) Full Attempt at Resuscitation: Full suspension of existing directives

Limited Attempt at Resuscitation Defined With Regard to Continue to refuse certain specific resuscitation procedures Specific Procedures: (chest compressions, defibrillation, intubation, etc.)

Limited Attempt at Resuscitation Defined With Regard to the Allow the anesthesiologist and surgical team to use clinical Patient’s Goals and Values: judgment in determining which resuscitation procedures are appropriate in the context of the situation and the patient’s stated goals and values.

(ASA, 2013) (AORN, 2014; ACS, 2014) Conscientious Objection

CRNA, Anesthesiologist, Surgeon, or any member of OR team:

. May withdraw from care before case begins if “limitations of intervention decisions” are irreconcilable with own moral views. Alternative for care needed.

. May voice concerns and present situation to manager, Hospital Ethics Committee or Hospital Legal Department if they find patient’s, surgeon’s, or anesthesia’s position in conflict with standards of care, ethical practice, or institutional policies.

(AANA, 2015; ASA, 2013) In-Hospital Cardiac Arrest (IHCA)

. Overall risk of IHCA in Western countries: Between 1 and 5 per 1,000 hospital admitted patients (0.1% to 0.5%)

. IHCA: overall survival-to-discharge rate of 15-20%

. Only addresses survival - not cognitive or functional status.

(Sandroni et al., 2007) (Nunnally et al., 2015) . Overall risk of Perioperative Cardiac Arrest: 0.056% or 5.6 per 10,000 cases

. Total incidents of Perioperative Cardiac Arrest was 951 – 396 patients (41.6%) survived – 555 patients (58.4%) died

. Most arrests: General Anesthesia cases: 89.1%

. Largest subgroup: Intra-abdominal cases 16% (Nunnally et al., 2015) (Nunnally et al., 2015) University Hospital of Cologne 2007 – 2012 Data

. Overall incidence of perioperative cardiac arrest of 5.8/10,000 anesthetics – 169,500 anesthetics revealed 99 perioperative cardiac arrests

(Hohn et al., 2018) (Kalkman et al., 2016) (Kalkman et al., 2016) (Kalkman et al., 2016) Predictors of Functional Outcome after Intraoperative Cardiac Arrest (IOCA) (Constant et al., 2014) Predictors of Functional Outcome after Intraoperative Cardiac Arrest (IOCA) (Constant et al., 2014)

. 869,425 patients from 11 hospitals in France between 2000-2013

. 238 patients had IOCA (2.7 out of 10,000)

. 98 patients (40%) died intraoperatively

. 140 patients (60%) survived IOCA and admitted to ICU Predictors of Functional Outcome after Intraoperative Cardiac Arrest (IOCA) (Constant et al., 2014)

. Of the 140 patients which survived their IOCA –54% Survived through ICU –51% Survived through postoperative day 90 –45% Survived with a CPC* score of 1 or 2 on postop day 90

– *Cerebral Performance Category (CPC) score Predictors of Functional Outcome after Intraoperative Cardiac Arrest (IOCA) (Constant et al., 2014)

. Of the 238 patients who had an IOCA –32% Overall chance of survival through ICU discharge –30% Overall chance of survival through postop day 90 –27% Overall chance of survival with CPC 1 or 2 on day 90

Informed Consent for Anesthesia: Patients with Existing DNR . Ideal World – Reconsider DNR during a Preoperative Anesthesia Clinic visit

. Real World – Consent not completed before DOS or DNR not addressed and documented in Preop Evaluation

. Obtaining consent the DOS: does this limit the value of the discussion?

. Opportunity for patient to think over anesthetic options? Preoperative Discussion Required Reconsideration of DNR

Explain DNR options to patient: . Full suspension . Limited attempt re: procedures . Limited attempt re: goals/values . No suspension

(AANA, 2015; ASA, 2013) Preoperative Discussion Required Reconsideration of DNR

. Types of anesthesia - risks/benefits . Mechanical ventilation? . Severe hypotension, blood loss, respiratory depression, arrhythmias & treatments . Cardiopulmonary Arrest: incidence and survival in perioperative period vs in-hospital . Length of DNR Modification or Suspension – Needs to be decided Pre-operatively and documented – Ends with discharge from PACU? – Remain intubated into ICU? . Situation(s) when DNR is to be reinstated? . Document! (AANA, 2015; ASA, 2013; Franklin, 1992; Waisel et al., 2003) Barriers to Addressing DNR Orders . Never met patient before and you want me to discuss the patient’s wishes regarding death?

. Limited Training / Emphasis

. Production pressure

. Minor, straightforward cases

. Complex cases (Keffer, 1992; Waisel et al., 2003) Provider Management of Goals of Care in the OR

(Hadler et al., 2016) Barriers to Implementing DNR Orders

. Value dissonance between clinicians and patients – we prioritize the imminent danger of death but patients focus on their functional status

. Iatrogenic events / caused by surgeon or anesthesia

. Death does not belong in the OR

(Waisel et al., 2003) Anesthesiologist Management of Perioperative Do-Not-Resuscitate Orders: A Simulation-Based Experiment

(Waisel et al., 2009)

3 Case Report

Patient with DNR undergoing a minor ambulatory surgery

. PMH: metastatic pheochromocytoma

. Agreed plan: --Intubation with arterial line; vasoactives okay --No chest compressions or defibrillation under any circumstances

(Hickey et al., 2016) Case Report

73 yr M presents for R BKA for vascular insufficiency

PMH: severe CAD, PVD, stroke (right hemiplegia)

DNR in place

Unequivocally, he does not want CPR in perioperative period, regardless of its cause or positive prognosis

Agrees to spinal + sedation (Van Norman, 1998) Nuggets from Hug

“Does every patient need a surgical operation or other burdensome intervention before dying?”

Our role in Informed Consent: “free of bias, prejudice, and self-interest.”

Anesthesia residents should spend at least 2 months caring for post-surgical patients in ICU

How long did you spend working in the ICU?

Carl Hug, Jr., MD, PhD Professor of Anesthesiology, Emeritus (Hug, 2000); http://www.anesthesiology.emory.edu/faculty/hug-carl.html Emory University School of Medicine Systems in Practice

Communication is key when consenting a DNR patient for surgery

. If ACT model, does your attending anesthesiologist know about the ASA’s Reconsideration of DNR guidelines?

. Form plan to speak about DNR during consent process

. Be sure Surgery team is involved and “on the same page” Systems in Practice

. Communicate code status with entire OR staff before case begins

. Voice DNR status during operative Time Out

. Clarify code status in PACU/ICU Handoff

. Document! Next Steps

. Become familiar with professional guidelines

. DNR status as part of Time Out

. Allow for conscientious objectors to be replaced

. Identify individuals as resources

. Access current norms and understanding

. Education and simulation Questions?

. How do you and your group/department handle patients with DNR’s?

. Do you have a separate Anesthesia Consent? Does it have anything related to DNR on it? References

Administration on Aging. Administration for Community Living. Profile of Older Americans. 2015. Available at: https://aoa.acl.gov/Aging_Statistics/Profile/2015/4.aspx Accessed Mar 10, 2018.

American Association of Nurse Anesthetists. Reconsideration of Advance Directives, Practice Guidelines and Considerations for Policy Development. 2015. Available at: http://www.aana.com/resources2/professionalpractice/Documents/Reconsideration%20of%20Advanced%20Directives.pdf Accessed Dec 2, 2017.

American Bar Association. Division of Public Education. Law for Older Americans. 2017. Available at: http://www.americanbar.org/groups/public_education/resources/law_issues_for_consumers/patient_self_determination_act.html Accessed Feb 3, 2018.

American College of Surgeons. Statement on advance directives by patients: “do not resuscitate” in the operating room. Bull Am Coll Surg. 2014;99(1):42-43. Available at: https://www.facs.org/about-acs/statements/19-advance-directives Accessed Dec 2, 2017.

Association of PeriOperative Registered Nurses. AORN Position Statement: Perioperative Care of Patients with Do-Not-Resuscitate (DNR) Orders. 2014. Available at: https://www.aorn.org/guidelines/clinical-resources/position-statements Accessed Dec 2, 2017.

American Society of Anesthesiologists. Ethical Guidelines for the Anesthesia Care of Patients with Do Not Resuscitate Orders or Other Directives that Limit Treatment. Amended October 16, 2013. Available at: http://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/ethical-guidelines-for-the-anesthesia-care-of-patients.pdf Accessed Dec 2, 2017.

Byrne, S., Mulcaby, S., Torres, M., & Catlin, A. (2014). Reconsidering do‐not-resuscitate orders in the perioperative setting. Journal of PeriAnesthesia Nursing, 29(5), 354-‐360.

. References Constant, A. , Montlahuc, C. , Grimaldi, D. , Pichon, N. , Mongardon, N. , Bordenave, L. ,. . . Legriel, S. (2014). Predictors of Functional Outcome after Intraoperative Cardiac Arrest. Anesthesiology, 121 (3), 482–491. doi: 10.1097/ALN.0000000000000313.

Ewanchuk M, Brindley PG. Perioperative do-not-resuscitate orders–doing 'nothing' when 'something' can be done. Crit Care 2006, 10(4):219–223

Franklin, CM. Do-not-resuscitate orders in the presurgical patient. Journal of Clinical Anesthesia. 1992, 4(3): 181-4.

Hadler RA, Neuman MD, Raper S, Fleisher LA. Advance Directives and Operating: Room for Improvement? A A Case Rep 2016, 6(7):204-7. doi: 10.1213/XAA.0000000000000269.

Hickey, TR, Cooper, Z, Urman, RD, Hepner, DL, Bader, AM. An agenda for improving perioperative code status discussion. A A Case Rep. 2016 Jun 15;6(12):411-5. doi: 10.1213/XAA.0000000000000327.

Hohn, A. , Machatschek, J. , Franklin, J. & Padosch, S. A. (2018). Incidence and risk factors of anaesthesia-related perioperative cardiac arrest. European Journal of Anaesthesiology, 35(4), 266–272. doi: 10.1097/EJA.0000000000000685.

Hug, Jr., CC. Patient Values, Hippocrates, Science, and Technology: What We (Physicians) Can Do versus What We Should Do for the Patient. Rovenstine Lecture. Anesthesiology, 2000; 93:556–64

Jackson, S. Perioperative do-not-resuscitate orders. AMA Journal of Ethics Mar 2015, 17(3): 229-235. doi: 10.1001/journalofethics.2015.17.3.nlit1-1503

Kalkman, S. , Hooft, L. , Meijerman, J. M. , Knape, J. A. & van Delden, J. M. (2016). Survival after Perioperative Cardiopulmonary Resuscitation. Anesthesiology, 124(3), 723–729. doi: 10.1097/ALN.0000000000000873. References

Keffer, MJ, Keffer, HL. Do-not-resuscitate in the operating room: Moral obligations of anesthesiologists. Anesth Analg 1992, 74:901-5.

Kochanek KD, Murphy SL, Xu J,Tejada-Vera B. Deaths: Final Data for 2014. National Vital Statistics Reports. 2016, 65(4):10. Available at https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf Accessed Mar 10, 2018.

Law for Older Americans: Health Care Advance Directives. (2013, Mar 18). Retrieved from https://www.americanbar.org/groups/public_education/resources/law_issues_for_consumers/patient_self_determination_act/

North Carolina Department of the Secretary of State Advance Health Care Directive Registry. Forms. 2007. Available at https://www.sosnc.gov/ahcdr/Forms.aspx Accessed Feb 3, 2018.

Nunnally ME, O’Connor MF, Kordylewski H, Westlake B, Dutton RP. The incidence and risk factors for perioperative cardiac arrest observed in the national anesthesia clinical outcomes registry. Anesth Analg 2015, 120(2):364-70. doi: 10.1213/ANE.0000000000000527.

Patient Self-Determination Act of 1990, Pub. L. No. 101-508, 105 Stat. 1388-44-115

Periyakoil VS, Neri E, Fong A, Kraemer H. Do Unto Others: Doctors' Personal End-of-Life Resuscitation Preferences and Their Attitudes toward Advance Directives. PLOS ONE 2014, 9(5): e98246. doi: 10.1371/journal.pone.0098246

Rothenberg, DM: Informed refusal – DNR orders in the patient undergoing anesthesia and surgery and at the end of life, Clinical Ethics in Anesthesiology: A Case-Based Textbook. Edited by Van Norman, GA, Jackson, S, Rosenbaum, SH, Palmer, SK. New York, Cambridge University Press, 2011, pp 13-26.

Sandroni, C, Nolan, J, Cavallaro, F, Antonelli, M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med 2007, 33: 237. doi:10.1007/s00134-006-0326-z References

Truog, R. “Do not resuscitate” orders during anesthesia and surgery. Anesthesiology. 1991; 74(3):606-8.

Van Norman G. Ethics in Medicine. University of Washington. 1998. Available at: http://depts.washington.edu/bioethx/topics/dnrau.html Accessed Feb 5, 2018.

Waisel, D, Jackson, S, Fine, P. Should do-not-resuscitate orders be suspended for surgical cases? Curr Opin Anaesthesiol 2003, 16:209–214. doi: 10.1097/01.aco.0000064041.76880.4d

Waisel DB, Simon R, Truog RD, Baboolal H, Raemer DB. Anesthesiologist management of perioperative do-not-resuscitate orders: A simulation-based experiment. Simul Health 2009, 4(2):470–6. doi: 10.1097/SIH.0b013e31819e137b

Wynn, S. (2014). Decisions by surrogates: An overview of surrogate consent laws in the United States. American Bar Association. Available at https://www.americanbar.org/content/dam/aba/publications/bifocal/BIFOCALSeptember-October2014.pdf Accessed Jun 29, 2019