Abstract
This case series investigates whether do-not-resuscitate orders were reevaluated before surgery among patients treated at 1 health system.
Individuals with do-not-resuscitate (DNR) orders may undergo surgery for symptom relief or to treat reversible conditions. Resuscitative procedures, such as intubation, are frequently necessary to deliver anesthesia and sedation safely. Guidelines recommend that each patient’s DNR order be reevaluated preoperatively to ascertain the need for modification or temporary suspension.1,2 Available evidence suggests incomplete implementation of such guidance.3,4,5,6 We performed a retrospective analysis of orders and documentation describing perioperative management of patients’ DNR orders at 1 academic health system in the US.
Methods
We conducted a retrospective case series of all adult inpatients admitted to any of 5 hospitals within the University of Pennsylvania Health System between March 2017 and September 2018 who had a DNR order placed in the medical record during admission and subsequently underwent a procedure requiring anesthesia care during the same admission. Medical records were manually reviewed to verify whether the DNR order was in place at the time surgical intervention was discussed. We reviewed notes and orders for eligible cases to identify goals of care discussions conducted within 48 hours before the procedure and the outcome. We collected demographic, physician, and case characteristics for patients meeting inclusion criteria as well as hospital policies regarding documentation. The primary outcome was the presence of a preoperative note or order documenting code status discussion or change. The University of Pennsylvania Institutional Review Board approved this study and waived the requirement for informed consent because of its retrospective nature and minimal risk to subjects. Excel, version 16.16.27 (Microsoft), and R, version 4.0.0 (The R Foundation) were used to analyze the data. χ2 (Excel) and Fisher exact test (R) were performed to assess statistical significance. The threshold for statistical significance was P < .05.
Results
Of the 27 665 inpatient procedures we identified across hospitals during the study period, 444 cases (1.6%) met the inclusion criteria. Participants had a mean (SD) age of 75 (13) years (95% CI, 72-77 years); 247 participants (56%) (95% CI, 55%-57%) were women, and the cohort was predominantly composed of White individuals (300 [68%]; 95% CI, 65%-71%) (Table). A total of 426 participants (96%; 95% CI, 90%-100%) had an American Society of Anesthesiologists (ASA) physical status score of 3 or higher. The most common procedures performed included endoscopy, hip fracture repair, and gastrostomy or jejunostomy. A total of 237 patients (53%; 95% CI, 51%-56%) received general anesthesia. Reevaluation of code status was documented in 126 cases (28%, 95% CI, 25%-31%). Code status orders were changed in 20 of 126 cases (16%; 95% CI, 7%-24%), and a note was filed without a corresponding order for 106 of 126 patients (84%; 95% CI, 75%-95%). In most cases (109 of 126 [87%]; 95% CI, 78%-95%) in which documented discussion occurred, DNR orders were suspended. Of 126 cases in which a discussion was documented, participants included surgeons 10% of the time (13 cases; 95% CI, 8%-13%), members of the anesthesia team 51% of the time (64 cases, 95% CI, 49%-53%), and medicine or palliative care clinicians 39% of the time (49 cases, 95% CI, 37%-41%).
Table. Patient and Case Characteristics and Association With Documentation of a Code Status Discussion.
| Characteristic | No. (%) | P value | ||
|---|---|---|---|---|
| Total (N = 444) | Perioperative code status discussion documented | No documented discussion identified | ||
| Age, y | ||||
| 18-64 | 97 (22) | 22 (23) | 75 (77) | .06 |
| 65-79 | 143 (32) | 35 (24) | 108 (76) | |
| ≥80 | 204 (46) | 69 (34) | 135 (66) | |
| Sex | ||||
| Female | 247 (56) | 69 (28) | 178 (72) | .81 |
| Male | 197 (44) | 57 (29) | 140 (71) | |
| Racea | ||||
| Black | 93 (21) | 19 (20) | 74 (80) | <.01 |
| White | 300 (68) | 84 (28) | 216 (72) | |
| Other or unknownb | 51 (11) | 23 (45) | 28 (55) | |
| ASA physical status score | ||||
| 2 | 18 (4) | 2 (11) | 16 (89) | .02 |
| 3 | 271 (61) | 69 (25) | 202 (75) | |
| ≥4 | 155 (35) | 55 (35) | 100 (65) | |
| Consenting partyc | ||||
| Patient | 266 (61) | 60 (23) | 206 (77) | <.01 |
| Surrogate | 171 (39) | 64 (37) | 107 (63) | |
| Anesthesia type | ||||
| General | 237 (53) | 69 (29) | 168 (71) | .70 |
| Otherd | 207 (47) | 57 (28) | 150 (72) | |
| Emergency status | ||||
| Emergent | 55 (12) | 21 (38) | 34 (62) | .08 |
| Elective | 389 (88) | 105 (27) | 284 (73) | |
| Procedures by servicee | ||||
| Surgicalf | 229 (52) | 74 (32) | 155 (68) | .04 |
| Hip fracture repair | 43 (10) | 14 (33) | 29 (67) | |
| Gastrostomy or jejunostomy | 28 (6) | 6 (21) | 22 (79) | |
| Exploratory laparotomy | 24 (5) | 7 (29) | 17 (71) | |
| Medicalg | 215 (48) | 51 (24) | 164 (76) | |
| Endoscopy | 148 (33) | 38 (26) | 110 (74) | |
| Bronchoscopy | 21 (5) | 3 (14) | 18 (86) | |
| Transesophageal echocardiogram | 9 (2) | 2 (22) | 7 (78) | |
| Hospital policy for perioperative management of DNR ordersh | ||||
| Written policy encouraging discussion | 389 (88) | 89 (23) | 300 (77) | <.01 |
| Written policy plus additional initiatives, including procedure-specific DNR form | 55 (12) | 37 (67) | 18 (33) | |
Abbreviations: ASA, American Society of Anesthesiologists; DNR, do not resuscitate.
Data on self-reported race were obtained from the electronic medical record and grouped race data into Black, White, and other for the purposes of this analysis.
Other included the following races: Asian, Pacific Islander, Native American, other (as reported by the patient), and unknown (patient did not report).
Copies of consent forms for 7 patients could not be obtained.
Other types included monitored anesthesia care and regional anesthesia.
The reported P value reflects comparison of aggregated discussion rates for surgical vs medical procedures. Disaggregated data are presented for the top 3 procedure types for each group.
Surgical specialties included cardiac surgery, colorectal surgery, otolaryngology, endocrine-oncologic surgery, emergency surgery or acute care surgery, general surgery, gastrointestinal surgery, neurosurgery, oromaxillofacial surgery, orthopedic surgery, plastic surgery, podiatry, thoracic surgery, trauma surgery, urology, and vascular surgery.
Medical specialties included cardiology (including electrophysiology), gastroenterology, and pulmonology.
At the time of data collection, written policies for perioperative management of DNR orders were obtained from all 5 hospitals. Physicians at 1 institution were routinely using a form provided by that institution to document perioperative goals of care discussions. Use of similar forms was not observed at the other institutions during the study period.
Documentation rates were higher in patients with a higher ASA physical status score (35% in patients with an ASA physical status score ≥4 [55 of 155] vs 25% in those with an ASA physical status score ≤3 [71 of 289]; P = .02). The likelihood of a documented preoperative code status discussion did not vary by anesthesia type (29% for general anesthesia [69 of 237 cases] vs 28% [57 of 207 cases] for other modalities; P = .70). Although each hospital had a written policy encouraging rediscussion of code status before surgical intervention, 1 hospital reported additional measures to increase documentation of such discussions, including provision of a procedure-specific DNR form. Documentation of preoperative code status discussions was higher at this site vs other hospitals (67% [37 of 55 cases] vs 23% [89 of 389 cases]; P < .01).
Discussion
In a sample of patients with preexisting DNR orders treated at an academic health system, fewer than 1 in 5 patients had a documented discussion of code status before surgery. Additional strategies, such as development of institutional protocols facilitating perioperative management of advance directives, identification of local champions, and patient education, should be explored to improve guideline adherence. This study had several limitations. Although we assessed compliance at 5 hospitals with individual perioperative DNR protocols, they are all within the same health system and may not represent the entire scope of practice in this area. We also were able to evaluate only discussion of goals of care as documented in the electronic medical record, and, as such, may have underestimated the frequency with which these conversations occurred.
References
- 1.American College of Surgeons Board of Regents . Statement on advance directives by patients: “do not resuscitate” in the operating room. American College of Surgeons. January 3, 2014. Accessed March 5, 2021. https://www.facs.org/about-acs/statements/19-advance-directives [PubMed]
- 2.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. Reaffirmed October 17, 2018. Accessed March 5, 2021. https://www.asahq.org/standards-and-guidelines/ethical-guidelines-for-the-anesthesia-care-of-patients-with-do-not-resuscitate-orders-or-other-directives-that-limit-treatment.
- 3.Urman RD, Lilley EJ, Changala M, Lindvall C, Hepner DL, Bader AM. A pilot study to evaluate compliance with guidelines for preprocedural reconsideration of code status limitations. J Palliat Med. 2018;21(8):1152-1156. doi: 10.1089/jpm.2017.0601 [DOI] [PubMed] [Google Scholar]
- 4.Waisel DB, Simon R, Truog RD, Baboolal H, Raemer DB. Anesthesiologist management of perioperative do-not-resuscitate orders: a simulation-based experiment. Simul Healthc. 2009;4(2):70-76. doi: 10.1097/SIH.0b013e31819e137b [DOI] [PubMed] [Google Scholar]
- 5.Coopmans VC, Gries CA. CRNA awareness and experience with perioperative DNR orders. AANA J. 2000;68(3):247-256. [PubMed] [Google Scholar]
- 6.Hadler RA, Neuman MD, Raper S, Fleisher LA. Advance directives and operating: room for improvement? A Case Rep. 2016;6(7):204-207. doi: 10.1213/XAA.0000000000000269 [DOI] [PMC free article] [PubMed] [Google Scholar]
