Suspending Do Not Resuscitate/Do Not Intubate Orders for Image-Guided Procedures

Interventional radiologists (IRs) often care for critically ill patients, providing both treatment and palliation. For example, a recent study found that patients died within 30 days of 9% of inpatient image-guided procedures and within 6 months of 7% of outpatient image-guided procedures. ¹ It is also not uncommon for these patients to have do not resuscitate and/or do not intubate (DNR/DNI) orders or other advance directives expressing patients' wishes to refuse resuscitation and/or intubation in the event of a cardiac arrest or the loss of a protected airway. ² When asked to perform a procedure for these patients, IRs can face a few different ethical dilemmas: the patient may want to keep the DNR/DNI order in place for their procedure, the documented code status may conflict with patient or family preferences, or respecting such preferences in the face of a code can be disturbing for the IR and/or members of their team. This article considers each of these issues with suggestions of how to best navigate them.

Issues to Consider Prior to Suspension of DNR/DNI

Required Perioperative Suspension of DNR/DNI

Consider a 68-year-old woman with multiple comorbidities who presents with acute gangrenous cholecystitis. You are consulted for cholecystostomy tube placement since the surgical team does not believe she would survive surgery. The patient has DNR/DNI orders and wants to keep them in place for the procedure, but your practice requires the suspension of such orders during cases.

Patients have the right to choose what happens to their bodies, including forgoing resuscitation efforts during a procedure. ² Although the procedure may increase the risk of needing resuscitation, it is not unreasonable for someone to want to undergo a minimally invasive procedure for treatment or palliation while not wanting to be resuscitated if something unintended happened. Forcing patients to choose between a procedure and their preference for DNR/DNI or suspending it automatically places patients and families in an unfair situation and undermines our professional commitment to patient autonomy. ³ Notably, this is different from situations in which the procedure is highly likely to not provide meaningful benefit, to cause harm, or to require resuscitation, leading to death. Clinicians are not obligated to provide care that they believe is likely futile and should not perform a procedure with DNR/DNI in place as a means of hastening death. ⁴ Differentiating these situations relies on an understanding of not only clinical factors but the patient's goals of care and preferences, which is why it is recommended to facilitate a discussion with the patient and family when faced with a request to perform a procedure with a DNR/DNI order in place and make a shared decision about how best to proceed. ^{5 6} The patient may decide to suspend the DNR/DNI or make a reasonable case to proceed with the DNR/DNI in place.

Historically, mandatory perioperative suspension of DNR/DNI was not uncommon ³ and the authors know of IR practices with these policies still in place. The practice likely stems at least in part from complication and 30-day mortality rates being common quality metrics. There is a common feeling among clinicians that the goal of healthcare is to prolong life and that letting the patient die on their watch is a disservice. ⁷ Others would argue that dying is a natural part of life and prolonging life at all costs can be harmful, but it can be difficult for us to balance these motivations. ⁸

Both the American College of Surgeons and American Society of Anesthesiology now advocate against mandatory suspension of DNR/DNI orders and instead recommend reconsideration, in which clinicians rediscuss the DNR/DNI status prior to procedures, considering perioperative risks and the patient's personal values. ^{5 6} Although no such guidelines exist for IR, this issue may be particularly salient for our specialty given how often we care for critically ill patients and the minimally invasive nature of our procedures. The authors believe IRs should adopt a similar approach of rediscussing DNR/DNI status and goals of care when faced with this dilemma and avoid unilaterally requiring periprocedural suspension. Even with such an approach, the authors suspect that the number of cases where patients opt to remain DNR/DNI would be small and unlikely to substantially affect overall quality metrics.

Prior DNR/DNI Orders May Not Reflect the Current Goals of Care

Consider a 75-year-old man admitted with COVID-19 pneumonia. Shortly after admission, he is referred for thrombectomy in the setting of acute proximal middle cerebral artery occlusion with hemiplegia and altered mental status. He has DNR/DNI orders documented when he was admitted because he “did not want to end up in a vegetative state.” His partner, who is his medical power of attorney, says the DNR/DNI orders should be suspended for the case. The procedure is complicated by perforation and hemorrhage, requiring intubation with low likelihood of significant neurologic recovery.

This case raises a couple of different issues including the importance of re-clarifying goals of care and code status in the periprocedural setting as well as surrogate decision making. DNR/DNI status is a helpful means of indicating patients' preferences and potentially avoiding harmful interventions near the end of life, but it is also limited, particularly when a code status is propagated across multiple notes and episodes of care. It is not uncommon for someone's goals of care and preferences to change over time or when faced with changes in their health, even throughout a single hospitalization—people change their minds. ⁹ Likewise, studies have shown that many patients with DNR/DNI orders in place would opt for cardiopulmonary resuscitation and/or intubation in certain clinical scenarios, ^{10 11} and the choice to be made for DNR/DNI can be substantially influenced by the context and means by which the choice is discussed. ^{12 13} This is another reason why it is important to rediscuss code status prior to an image-guided procedure and ensure it aligns with the current goals of care, considering the potential benefits, risks, and alternatives of the procedure. It can also be helpful to clarify the duration of a change in code status, that is, whether the change is just for a single procedure or intended to persist going forward as well.

IRs may be reluctant to routinely adopt such an approach given time constraints or concern about stepping on the toes of referring clinicians by facilitating these discussions. ¹⁴ However, the authors believe these conversations can be incorporated into clinical workflows and consent conversations without substantially increased time or risk of upsetting other services. For example, when discussing a potential procedure, one can broach the topic by saying “Hey, I noticed that you indicated in the emergency department that you didn't want us to resuscitate you if your heart stopped or you were unable to breathe on your own, is that still what you prefer even during this procedure?” Another approach is to start patient interactions by asking their understanding of their clinical status and why you are meeting. This often efficiently provides a sense of baseline understanding, values, and goals with minimal prompting and time.

In addition to clarifying goals of care, this case also raises a potential issue with surrogate decision making. If a patient is incapacitated, another person can make a decision on their behalf, either via a pre-appointed preferred surrogate (e.g., medical power of attorney) or default surrogate (e.g., family member) if no preferred surrogate has been designated or is available. ¹⁵ When discussing care via a surrogate, clinicians are expected to attempt to ensure that the person is exercising substituted judgment, conveying what the patient would want, not necessarily what they would want. ¹⁵ This can be challenging to assess, but the fact that the patient in the case chose to be DNR/DNI shortly before his surrogate is indicating the opposite should raise the suspicion that he may not be exercising substituted judgment. In such a case, one can gently raise the issue by saying something to the effect of, “I hear you saying that your partner would want to suspend the DNR/DNI status and proceed with the procedure. I just want to double check, because he indicated in the emergency department last night that he would not want to be resuscitated, because he did not want to end up in a vegetative state.”

Moral Distress and the Second Victim

Consider an 87-year-old woman with severe pulmonary hypertension who chooses to keep her DNR/DNI order in place during tunneled catheter placement. The patient's cardiopulmonary status rapidly deteriorates during sedation. Her preferences are respected, and she dies. A technologist present for the procedure feels this was wrong, that the team “just let her die,” and files a safety report.

Even when goals of care and code status are clarified, respecting those preferences can raise additional issues such as moral distress and the second victim phenomenon. Moral distress in healthcare is often used to describe the distress associated with feeling compelled to do something that one believes is morally wrong. ¹⁶ For example, the technologist who felt the death was wrong may not have felt empowered to raise that concern prior to the case or was unaware that it was a possible outcome. Often this issue disproportionately affects members of the team who feel subordinate to others, for example, trainees, nurses, and technologists more than attending physicians. ¹⁶ However, even when a team member agrees that respecting the patient's preferences was the right thing to do, cases with unintended adverse outcomes can still be distressing for those involved. This is particularly true for proceduralists where there is often a more immediate, direct relationship between a clinical decision and the unintended outcome. ¹⁷ Clinicians can feel personally responsible and that it could have been prevented if they had done something differently. ^{17 18} Although this can also cause a sense of moral distress, it is more often referred to as the “second victim phenomenon,” referring to the clinician as the second victim in the setting of an adverse event.

The moral distress associated with feeling compelled to do something that one feels is wrong can be lessened if not prevented by ensuring all members of the team have a shared understanding prior to such case, empowering them to voice their concerns, and providing the option, when feasible, for them to opt out of the case. ¹⁹ For example, it can be helpful going into such case to have a brief team huddle (or as part of the time out process) and note that the patient prefers to remain DNR/DNI for the case and understands that this means she will not be resuscitated if something unexpected occurs. Avoiding the second victim phenomenon is more challenging, as it seems to stem from a generally positive personal commitment to one's patients. In such situations, a support network can be invaluable both at and outside of work. ¹⁷ Practices and societies can also help by creating forums where clinicians can connect with their colleagues and discuss distressing cases in a safe space. Practices could also provide coverage if the clinician needs time and space after such a case in a manner that does not add to that person's sense of guilt.

Conclusion

IRs often care for critically ill patients, and it is not uncommon for these patients to have DNR/DNI orders in place. In such cases, IR practices should not require patients to suspend their DNR/DNI status to receive care or do so automatically. Instead, professional societies recommend clarifying the goals of care and code status considering the risks and benefits of a potential procedure. This means that there may be cases where the most ethical means of supporting the patient's goals of care is proceeding with a case with DNR/DNI orders in place. These cases are unlikely to be common but can be morally distressing for those involved if an unintended outcome occurs. Thus, it is important to be proactive and provide support for the team members involved.

Funding Statement

Funding None.