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Table.  Patient and Case Characteristics and Association With Documentation of a Code Status Discussion
Patient and Case Characteristics and Association With Documentation of a Code Status Discussion
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
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 PubMedGoogle ScholarCrossref
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 PubMedGoogle ScholarCrossref
5.
Coopmans  VC, Gries  CA.  CRNA awareness and experience with perioperative DNR orders.   AANA J. 2000;68(3):247-256.PubMedGoogle 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 PubMedGoogle Scholar
Research Letter
September 22, 2021

Perioperative Management of Do-Not-Resuscitate Orders at a Large Academic Health System

Author Affiliations
  • 1Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City
  • 2Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 3Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Surg. 2021;156(12):1175-1177. doi:10.1001/jamasurg.2021.4135

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.3-6 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%).

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.

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Article Information

Accepted for Publication: June 22, 2021.

Published Online: September 22, 2021. doi:10.1001/jamasurg.2021.4135

Corresponding Author: Rachel A. Hadler, MD, Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 6 John Colloton Pavilion, Iowa City, IA 52242 (rachel-hadler@uiowa.edu).

Author Contributions: Dr Hadler had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hadler, Neuman.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Hadler, Fatuzzo.

Critical revision of the manuscript for important intellectual content: Hadler, Sahota, Neuman.

Statistical analysis: Hadler, Fatuzzo, Neuman.

Administrative, technical, or material support: Neuman.

Supervision: Hadler, Neuman.

Conflict of Interest Disclosures: Dr Neuman reported receiving grants from the Patient-Centered Outcomes Research Institute, the National Institutes of Health, the American Society of Anesthesiologists, the International Anesthesia Research Society, and the Anesthesia Patient Safety Foundation outside the submitted work. No other disclosures were reported.

Additional Contributions: The authors would like to acknowledge the assistance of Rachel Kohn, MD, MSCE, University of Pennsylvania Perelman School of Medicine.

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
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 PubMedGoogle ScholarCrossref
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 PubMedGoogle ScholarCrossref
5.
Coopmans  VC, Gries  CA.  CRNA awareness and experience with perioperative DNR orders.   AANA J. 2000;68(3):247-256.PubMedGoogle 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 PubMedGoogle Scholar
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