Alyssa Bruno, SRNA

DNR IN THE OR: ETHICS FOR

ANESTHETISTS

It is your professional obligation

WHY ETHICS?

It is your obligation to society

WHY ETHICS?

GALLUP POLL

http://www.gallup.com/poll/180260/americans-rate-nurses-highest-honesty-ethical-standards.aspx

It is your obligation to yourself

WHY ETHICS?

What causes moral distress for CRNAs?

“the delivery of aggressive care to patients who will not benefi t from that care,

ignoring the wishes of patients regarding treatment,

working with unsafe levels of nursing staff ,

and working with incompetent physicians.”

MORAL DISTRESS

Which CRNAs experience the most moral distress?

“it appears that younger nurse anesthetists may lack ethical decision making experience and, as a result, encounter greater moral distress when faced with ethical dilemmas.”

“CRNAs with lesser years of experience had higher moral distress, which increased with increasing experience.”

MORAL DISTRESS

Your chosen profession demands a high level of ethical decision making

Patients expect you to be an expert

Ethical decision making can be emotionally and physically draining – take care of yourself

THE BOTTOM LINE

Understand the ethical framework for end-of-life decision making

Understand the process of “required reconsideration” for surgical patients with DNR orders

Understand the characteristics and perspectives of surgical patients with DNR orders, including strategies for conducting diffi cult conversations

OBJECTIVES

Advanced Directives

Living Will Applies only to patients that are incompetent (cannot make

their own decisions) AND who have an end-stage medical condition OR are permanently unconscious

Can be filled out by anyone; need two witnesses

Durable Power of Attorney for Healthcare Designates a surrogate decision maker in case the patient

cannot make or communicate his or her own treatment decisions

Can be filled out by anyone, but it is recommended that a lawyer helps draft it

TERMINOLOGY

Order in the patient’s chart

System defaults to “full resuscitation” Don’t assume that a conversation has taken place!

If the patient is competent – you have to ask! Even if the patient has a living will, it does not dictate code status for this admission

CODE STATUS

What is a DNR order?

“A do-not-resuscitate order prohibits the use of resuscitation measures in the event of a cardiopulmonary arrest and applies only to the unresponsive, clinically pulseless patient” -Card iopu lmonary Resusc i ta t ion and Do-Not -Resusc i ta te Orders : A Gu ide fo r C l in ic ians . Loer tscher , et . a l , 2010

-Also called DNAR (do not attempt resuscitation) or AND (allow natural death)-May or may not be accompanied by DNI order (do not intubate)-May be indicated as part of an advanced directive or ordered by a physician after a documented conversation with the patient or the patient’s legal representative

DNR ORDERS

Should we ask all surgical patients about their advanced directives?

ETHICS AND SURGERY

A retrospective analysis of 250 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project

2005-2010

Total of 1.3 million surgical cases reviewed; looked at those requiring CPR with BLS or ACLS within 30 days of the operation

6,382/1.3 million surgical patients required CPR within 30 days of the operation (1/203)

OUTCOMES

OUTCOMES

86% of the cardiac arrests occurred post-op; only 0.07% occurred intra-op

Overall 30-day mortality in the entire data set was 1.7%;

Patients who received CPR had a mortality rate of 71.6% (p<0.001)

OUTCOMES

It is rare for surgical patients to experience an intra-operative cardiac arrest…

…however, ~1 in 200 surgical patients have a cardiac arrest within 30 days of surgery

Surgical patients that experience a peri-operative cardiac arrest are likely to die within 30 days of the cardiac arrest (70% mortality rate)

Talk about advanced directives!!

ALL THESE STATISTICS

The Advanced Directive Process at York

Legally, we are required to ask all patients on admission if they have an advanced directive: yes or no question.

ADVANCED DIRECTIVES

LEGAL ISSUES

http://www.cobar.org/index.cfm/ID/1816/subID/6626/CLPE/Summary-of-the-Patient-Self-Determination-Act-from-the-Commission-on-Law-and-Aging-at-the-ABA/

The Advanced Directive Process at York

Legally, we are required to ask all patients on admission if they have an advanced directive: yes or no question.

If they say no, we have to “provide written information” - an information booklet

There is no legal requirement to have a discussion about advanced directives, or end of life wishes; this discussion is left up to the providers

ADVANCED DIRECTIVES

1. What is the prevalence of DNR orders among surgical patients?

2. Which surgeries are commonly performed on DNR patients?

DNR PATIENTS IN THE OR

“Medical conditions that may require anaesthesia for operative interventions in a patient with a DNAR decision include:provision of a support device (e.g. a feeding tube)urgent surgery for a condition unrelated to the underlying

chronic problem (e.g. acute appendicitis)urgent surgery for a condition related to the underlying

chronic problem but not believed to be a terminal event (e.g. bowel obstruction)

procedure to decrease pains (e.g. repair of fractured neck of femur)

procedure to provide vascular access”

COMMON SURGERIES

From Do Not Attempt Resuscitation (DNAR) Decisions in the Perioperative Period, published by The Association of Anaesthetists of Great Britain and Ireland

3. What are the outcomes of DNR patients that go to the OR?

OUTCOMES

A retrospective analysis of 120 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project

2005-2008

Total of 4128 DNR patients matched with 4128 non-DNR patients

Mean age: 79.1 yearsMost patients were female (58.2%) and white (81.5%)

OUTCOMES

DNR Order

No DNR Order p-value

Lost independent functional status between illness

onset and day of surgery

27.1% 12.8% <0.001

Number of comorbidities 4.3 3.1 <0.001

Intra-op MI, cardiac arrest, unplanned intubation

0.8% 0.6% 0.43

Complication rate 31% 26.4% <0.001

Number of complications 1.9 2 0.70

Died within 30 days of surgery

23.1% 8.4% <0.001

CASE STUDY

71 y/o female with colon cancer presents for a low-anterior resection at York Hospital

Post-op, admitted to ICU; she develops a surgical site infection and sepsis over the following week

Intubated, sedated, unresponsive

Patient has a DNR order documented in the chart

After two weeks in the ICU, the team recommends trach/PEG

You are sent to pre-op the patient!

CASE STUDY

What ethical principles should guide your conversations with this patient’s family?

ETHICAL PRINCIPLES

• Beneficence

• Nonmaleficence

• Respect for Autonomy

• Justice

“The rights of an individual to have control over their own body and to be allowed to make decisions about their medical treatment are paramount.” – From Do Not Attempt Resuscitation Decisions in the Perioperative Period by The Association of Anaesthetists of Great Britain and Ireland

Should a DNR order be automatically suspended in the peri-operative period?

Reasons to suspend the DNR order

Reasons to continue the DNR order

THE BIG QUESTION

1. Fully rescind the DNR order and make full resuscitation attempts during the anesthetic and immediate post-op period

2. Leave the DNR order in place during the peri-operative period, and only provide anesthesia that is compatible with the patient’s/family’s wishes

3. Allow the surgical team, including the anesthetist, to use their judgment about which resuscitative procedures are appropriate, keeping the patient’s/family’s goals and values in mind

After talking to the patient, get the whole team on board

REQUIRED RECONSIDERATION

DNR TO THE OR - AT YH

18 terminally ill patients, 1994-1995

Question 1: Would you undergo any type of surgery?

PATIENT PERSPECTIVE

Anesthesia & Analgesia, 1997

18 terminally ill patients, 1994-1995

Question 2: How should your DNR order be interpreted prior to surgery?

PATIENT PERSPECTIVE

Anesthesia & Analgesia, 1997

Take home:

Patient preferences vary

“A patient’s desire for DNR suspension in the operating room cannot be assumed.”

PATIENT PERSPECTIVE

Anesthesia & Analgesia, 1997

Team recommends trach/PEGPt has a DNR orderRecommendations:

Talk to the family Elicit goals of surgery and end-of-life goals Present the three options of required reconsideration

fully rescind DNR order rescind DNR order but leave resuscitation decisions up to

surgical team leave DNR order in place

Respect the family’s decision!

CASE STUDY

CASE STUDY 2

Dorothy Glass, 85 y/o.

PMH: Hep C, cirrhosis, liver cancer, esophageal varices, CHF (EF 35%), IDDM, depression, arthritis

PSH: EGD with banding 11/2014, Right THA (2001), Tubal ligation (1972)

HPI: Pt had syncopal episodes in her nursing home. Went to the ED, diagnosed with sick sinus syndrome. Cardiology recommends a pacemaker/ICD.

You are sent to pre-op the patient!

CASE STUDY 2

GLASS, DOROT

GLASS, DOROTHY A 85

10/22/1929

F

60355821

YH ED

92355

FULL RESUSCITATION

CASE STUDY 2

What do you do?

CASE STUDY 2

Focus on the patient and be ready to listen Eliminate distractions Sit at eye level Ask if the patient would like loved ones to be present Establish trust: recognize and validate the patient’s emotions Avoid vague and technical terminology Provide context

Describe procedures involved in normal anesthetic course Provide risks and alternatives to anesthesia

Ask patient to state his/her goals for surgery and for end-of-life

Closing the conversation Offer a professional recommendation based on patient condition and

priorities Clarify the difference between withholding CPR and withholding

treatment

DIFFICULT CONVERSATIONS

-Cardiopulmonary Resuscitation and Do-Not-Resuscitate Orders: A Guide for Clinicians. Loertscher, et. al, 2010

Approximately 25% of DNR patients that go to the OR die within 30 days of surgery

However, all patients have the right of autonomy

DNR orders should NOT be automatically suspended for patients going to the OR

DNR patients are individuals with diff erent wants, needs and goals

Have a diffi cult conversation

SUMMARY

The Assoc i a t i on o f Anaes the t i s t s o f G rea t B r i t a i n and I re l and (2009 ) . Do No t At tempt Resusc i ta t i on (DNAR) dec i s i ons i n the pe r i ope ra t i ve pe r i od . Ava i l ab l e a t : h t tp : / /www.aagb i . o rg / s i t es /de fau l t /fi l es /dnar_09_0 .pdf. Accessed J anuary 5 , 2015 .  C l emency MV, Thompson N J . Do no t resusc i ta te o rde rs i n the pe r i ope ra t i ve pe r i od : pa t i en t pe rspec t i ves . Anes th Ana lg . 1997 ;84 (4 ) :859 -64 . Co l o rado Ba r Assoc i a t i on . Summary o f t he Pa t i en t Se l f De te rmina t i on Ac t f rom the Commiss i on o f Law and Ag ing a t t he ABA. Ava i l ab l e a t : h t tp : / /www.coba r.o rg / i ndex . c fm/ ID /1816 /sub ID/6626 /CLPE /Summary- o f- the -Pa t i en t -Se l f-De te rmina t i on -Ac t - f rom- the -Commiss i on - on -Law-and-Ag i ng -a t - the -ABA/ . Accessed J anua ry 16 , 2015 . J onsen , A. , S i eg l e r , M . , & Wins l ade , W. ( 2010 ) . C l i n i ca l e th i c s : A p rac t i ca l approach to e th i ca l dec i s i ons i n c l i n i ca l med i c i ne ( 7 th ed . ) . New Yo rk : McGraw H i l l , Med i ca l Pub . D i v i s i on . Kazaure HS , Roman S A , Rosentha l RA , Sosa JA . Ca rd i ac a r res t among surg i ca l pa t i en t s : an ana l ys i s o f i nc i dence , pa t i en t cha rac te r i s t i c s , and outcomes i n ACS-NSQIP. JAMA Surg . 2013 ;148 (1 ) :14 -21 . Kazaure H , Roman S , Sosa JA . H i gh mor ta l i t y i n su rg i ca l pa t i en t s w i th do -no t - resusc i ta te o rde rs : ana l ys i s o f 8256 pa t i en t s . A rch Surg . 2011 ;146 (8 ) :922 -8 . Loe r t sche r , L . , Reed , D . , Bannon , M . , & Mue l l e r , P. ( 2010 ) . Ca rd i opu lmonary resusc i t a t i on and do -no t - resusc i t a te o rders : A gu ide f o r c l i n i c i ans . The Amer i can J ourna l o f Med i c i ne , 123 (1 ) , 4 -9 . do i : 10 .1016 / j . amjmed.2009 .05 .029 Radzv in , L . ( 2011 ) . Mora l d i s t ress i n Ce r t i fi ed Reg i s te red Nurse Anes the t i s t s : Imp l i ca t i ons f o r nurs i ng prac t i ce . AANA Journa l , 79 (1 ) , 39 -44 . Re t r i eved November 16 , 2014 , f rom www.aana . com/aana j ourna l on l i ne .aspx Code o f E th i c s f o r t he Cer t i fi ed Reg i s te red Nurse Anes the t i s t . ( 2013 , J anua ry 1 ) . Re t r i eved November 16 , 2014 .

QUESTIONS?

References