Section 1: Palliative CarePalliative Surgery in the Do-Not-Resuscitate Patient: Ethics and Practical Suggestions for Management
Section snippets
Case
A 79-year-old woman with stage IV metastatic non–small cell lung cancer on hospice presents with increased hip pain. Her primary oncologist images the hip, and an impending hip fracture secondary to metastatic disease is diagnosed. She is offered an open reduction and internal fixation of her hip in the hopes of restoring some limited mobility and to provide pain relief at the end of her life so that she may attend her granddaughter’s wedding. She is adamant that she not be resuscitated in the
History of DNR orders in the perioperative period
Cardiopulmonary resuscitation (CPR) is the only medical intervention for which no consent is required, and an explicit physician’s order is necessary for it to be withheld. Originally described as treatment for intraoperative cardiac arrest, its use has become widespread outside the OR and outside the hospital. Whereas mortality for intraoperative cardiac arrest was relatively low (∼50%), survival figures for out-of-OR cardiac arrest were worse (10%–30%).7, 8
Through the 1960s and 1970s as the
Hospice patients
There is a common misunderstanding that patients who have enrolled in hospice also have given up the desire for resuscitation. Designating oneself as DNR is not necessary for hospice care. Only 2 requirements must be met for someone to be eligible for hospice: (a) the patient, or designated surrogate, expressly desires to focus on comfort and quality of life, while forgoing curative therapies for the primary, life-threatening disease; and (b) a physician certifies that the patient has a life
Suggested practical approach to the preoperative evaluation of the DNR patient presenting for surgery
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Uniform policies suspending DNR orders before surgery are inappropriate and are not useful.
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It is essential and required that a discussion with the patient regarding values and goals take place and that those values and goals be discussed in the context of the specific procedure and anesthesia required.
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This discussion should be undertaken by the attending physician and not delegated.
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If resuscitation is to be limited, the patient may choose to appoint the anesthesiologist or surgeon as a
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Intraoperative and postoperative symptom management
The anesthesiologist is in a unique position to alleviate suffering. Focus should be not only on providing adequate analgesia but also on other common symptoms more common in the palliative care population: dyspnea, cough, sedation, anxiety, and nausea. In addition, the DNR patient may be older, sicker, and require larger doses of opioids, increasing the risk of postoperative delirium.18 Appropriate treatment of symptoms while minimizing the risk of complications is, of course, precisely the
Summary
Whereas palliative care in the United States was in its relative infancy just a decade ago, it has made tremendous strides in the intervening years. The central tenets of providing symptom management and comfort for all patients, no matter what the stage of their illness, and to address goals of care and personal values in the context of the patient-family unit, are widespread now. These tenets are consistent with the burgeoning movement toward patient- and family-centered care, away from
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Cited by (22)
Adult Perianesthesia Do Not Resuscitate Orders: A Systematic Review
2019, Journal of Perianesthesia NursingCitation Excerpt :The human and provider dimension is epitomized by a series of articles examining how anesthesia providers, surgeons, perioperative nurses, internal medicine physicians, and patients view the use of perianesthesia DNR orders. Significantly, only three studies focus on how perianesthesia patients feel about using their DNR orders during anesthesia.32,51,60 The remaining articles grouped within the human and provider dimension focus on how anesthesiologists, CRNAs, surgeons, and internists experience perianesthesia DNR orders.
The Challenge of Perioperative Advance Care Planning
2019, Journal of Pain and Symptom ManagementCitation Excerpt :The impact of an incomplete understanding of routine anesthetic practice is a common problem faced by anesthetists when interpreting AHD and NFR orders as they will often not have been ratified with the future possibility of surgery in mind.18 Knipe and Scott describe that NFR orders were routinely suspended in the intraoperative period by anesthetists for reasons such as concern that cardiac arrest can be caused iatrogenically and swift management can produce good outcomes; the belief that everything should be done to ensure patient survival in theater; and the impression of significant overlap between routine anesthetic interventions and aspects of CPR.17,19 In a recent survey of Australian anesthetists, 45.7% reported to “always” following an NFR order, with others reporting they “often,” “sometimes,” and “didn't” adhere to such orders.12
Revisiting code status in patients undergoing GI endoscopy with a “do not resuscitate” order
2019, Gastrointestinal EndoscopyPostoperative outcomes in patients with a do-not-resuscitate (DNR) order undergoing elective procedures
2018, Journal of Clinical AnesthesiaDo-Not-Resuscitate Orders in the Perioperative Environment: A Multidisciplinary Quality Improvement Project
2017, AORN JournalCitation Excerpt :This conversation and reevaluation should be a standard component of care. The risks, benefits, implications, and potential outcomes of anesthesia and surgery in relation to the DNR order must be discussed with the patient before initiating anesthesia and surgery.3,7,17-21,23 Nurses are competent and capable of initiating the discussion about DNR orders before surgery, and this is within the scope of nursing practice.24,25
Perioperative Palliative Care Considerations for Surgical Oncology Nurses
2017, Seminars in Oncology Nursing