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