#033 Peri-operative management of Do-Not-Resuscitate orders in the state of Wisconsin
Authors: Olivia Mac, Robert Biechler MD, Thomas Ebert MD, Arthur Derse MD JD, Bambi Wessel
Context: Patient with DNR orders in peri-operative period
Action: Surgical procedure performed on geriatric patient with previously instituted DNR orders
Incidence/Prevalence: About 15% of patients undergoing surgery have existing DNR orders (1, 2). Geriatric patients with existing DNR orders may undergo surgery and anesthesia for reasons such as improving comfort and quality of life, relieving pain, or facilitating care (3).
Underlying Science: The cause of cardiac arrest in the intra-operative period is multifactorial. A recent study looked at the risk factors, incidence, and survival associated with intraoperative cardiac arrest. The study found emergency surgery, functional dependence prior to surgery, and increasing amounts of transfusion during surgery were risk factors in the operating room. The incidence of cardiac arrest in the OR was 7.22/10,000. Mortality was 62% at 30 days post operative compared to 77.3% mortality associated with intra-hospital cardiac arrest and 90.4% mortality associated with out of hospital cardiac arrest. Secondary to increased survival with intra-operative cardiac arrest and the odds that the patients arrest being associated with surgical or anesthetic procedure is why DNR orders are often withdrawn prior to operative procedure (4).
Wisconsin State Law: The laws regarding DNR orders in the state of Wisconsin are not well defined, nor are there statements involving DNR orders in the peri-operative setting (5).
Policy at Froedtert Health/Medical College of Wisconsin: If a patient with an existing DNR order is undergoing a procedure in the OR, a plan should be developed between the physician and patient or patient’s decision makers as what to do when cardiopulmonary arrest occurs. The plan should be well documented prior to the procedure and followed through should resuscitation be required. Any suspended DNR order is automatically reinstated upon patient discharge from the post anesthesia care unit or therapeutic suite unless another plan has been made. If the physician performing the procedure does not wish to honor the patient’s wishes, the physician should assist in finding a physician who is willing to honor the patient’s wishes to perform the procedure (6).
Ethics: According to the guidelines of the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS), policies that automatically suspend existing DNR orders for patients undergoing surgeries may not represent the patients’ wishes and should be reconsidered. Advance directives involving procedures that limit resuscitation should be reviewed with the patient or the patient’s surrogates prior to anesthetic procedures, and should be modified based on the patient’s wishes. The patient should understand which procedures are necessary for the success of anesthetics and which are not before making decisions to modify their directives. Plans should also be made with the patient as whether to and when to reactivate the original DNR order post operatively. All modifications and decisions should be documented. In cases of conflict, decisions should be made in best to adhere to the patient’s wishes (7, 8).
Identify the Wisconsin legislation pertaining to patient’s and healthcare provider’s rights in regards to do-not-resuscitate (DNR) orders in the peri-operative period
Identify the Froedtert Hospital policy regarding DNR orders in the peri-operative period
Identify the recommendations by American Society of Anesthesiologist and American College of Surgeons regarding DNR orders in the peri-operative period
ACGME Competencies: Patient Care, Professionalism, Systems-Based Practice
Ewanchuk, M and Brindley, PG. (2006). Ethics Review: Perioperative do-not-resuscitate orders-doing ‘nothing’ when ‘something’ can be done. Critical Care. 10(4):219. http://ccforum.com/content/10/4/219. Accessed April 20, 2013.
Guarisco, KK. (2004). Managing do-not-resuscitate orders in the perianesthesia period. J of PeriAnesthesia Nursing. 19(5): 300-307.
Ball, KA. (2009). Do-not-resuscitate orders in surgery: Decreasing the confusion. AORN Journal. 89(1): 140-150.
Girotra, S, Nallanothu, BK, Spertus, JA, Li, Y, Krumholz, HM, and Chan, PS. (2012). Trends in survival after in-hospital cardiac arrest. New England Journal of Medicine. 317: 1912-1920.
Cohn, S. (2013, April 19). Personal interview.
Froedtert Health (2010). Do Not Resuscitate DNR (CPM.0063) Milwaukee, WI.
American Society of Anesthesiologists. (2008). Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders or Other Directives that Limit Treatment.
American College of Surgeons. Statement on Advance Directives by Patients: "Do Not Resuscitate" in the Operating Room. http://www.facs.org/fellows_info/statements/st-19.html. Accessed March 11, 2013.
Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.
Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
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