- Email: [email protected]
Understanding the perioperative do-not-resuscitate order
Perioperative Care and Operating Room Management 9 (2017) 9–11
Contents lists available at ScienceDirect
Perioperative Care and Operating Room Management journal homepage: www.elsevier.com/locate/pcorm
Understanding the perioperative do-not-resuscitate order☆ ⁎
T
Arvind Rajagopal , David M. Rothenberg Rush University, 1653 West Congress Pkwy, Chicago, IL 60612, United States
A B S T R A C T The primary goal of this article is to improve end-of-life (EOL) care in the perioperative period. Clinicians should be able to understand the ethical and legal foundations for the “do-not-resuscitate” (DNR) order to help patients and their families make decisions about EOL care, understand the concept of “required reconsideration” for DNR orders prior to surgical procedures, acknowledge that DNR orders are based either on the patient’s perception of their quality of life (QOL) or the physician’s determination of medical futility as it relates to the patient’s disease process, and appreciate the distinction between prolonging life and prolonging death in the perioperative setting.
1. Principles of medical ethics The main tenets of medical ethics are based on beneficence, nonmaleficence, social justice and autonomy. Beneficence, or “doing good”, should be determined from the patient’s perspective and therefore may differ from the physician’s point of view. Nonmaleficence, or “do no harm”, may include therapies which may attempt to prolong life (e.g. mechanical ventilation, extra corporeal membrane oxygenation) but in reality may be merely prolonging death. Social justice is often not practiced on an individual patient level, but is increasingly becoming an issue as the costs of health care continue to escalate. This comes into play when we resuscitate a patient and admit the patient to an intensive care unit on life support, who because of a lack of a DNR order now has had death prolonged and utilizes a service (i.e. critical care) that might otherwise have benefited a patient whose life might be prolonged. This is frequently the cause of excessive costs in medicine at the EOL. Finally, autonomy relates to the patient’s right to make decisions for themselves. John Stuart Mill gave the basis for autonomy in his 1840 treatise, “On Liberty” when he stated: “considerations to aid man’s judgement, exhortations to strengthen his will, can be offered to him, even obtruded upon him by others, but he himself makes the final judgement”.1 The foundation of the DNR order is based on this ethical principle of autonomy and also on the legal principle of informed consent. 2. Informed consent A landmark case Schloendorff versus Society of New York Hospital
☆ ⁎
illustrated the importance of informed consent.2 The patient sued the hospital for having undergone a surgical procedure when she had only consented to having a gynecologic exam under anesthesia. Judge Benjamin Cardozo, who ruled for the plaintiff, wrote: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages. This is true except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained.” While this future U.S. Supreme Court Justice had ruled for the plaintiff, no damages were awarded as the patient had sued the hospital but not the physicians. The hospital was declared immune because of “charitable immunity”. This was known as Schloendorff’s law and applied to non-profit hospitals until it was overturned in 1957 in another landmark case, Salgo vs. Leland Stanford Hospital Jr. University Board of Trustees.3 This case emphasized the aspect of the “informed” portion of “informed consent. The patient underwent translumbar aortography which resulted in lower extremity paralysis as a complication related to the procedure. The patient sued based on both the claim of medical negligence as well as on the claim of failure to disclose all possible complications of the procedure. The court found that physicians had a duty to disclose ”any facts which are necessary to form the basis of an intelligent consent by the patient to a proposed treatment”. This case highlighted the need for all pertinent topics of consent such as the nature, consequences, harms, benefits, risks and alternatives of a
Based on a presentation given at the 12th Annual Perioperative Medicine Summit (March 11, 2017), Fort Lauderdale, FL. Corresponding author. E-mail address: [email protected] (A. Rajagopal).
https://doi.org/10.1016/j.pcorm.2017.11.009 Received 3 October 2017; Accepted 2 November 2017 Available online 06 November 2017 2405-6030/ © 2017 Elsevier Inc. All rights reserved.
Perioperative Care and Operating Room Management 9 (2017) 9–11
A. Rajagopal, D.M. Rothenberg
treatment, to be discussed with the patient to make a truly “informed consent”.
In essence, the DNR order is purely a nursing order. It is unique in that it actually directs clinicians to not do something and applies to CPR only. Interpretation of the DNR order by physicians has been varied over the years. Physicians have on occasion been known to perform what has been called a “slow” or “show” code. This paternalistic approach of physicians would constitute a violation of medical ethics and should be avoided. This is used by physicians who have failed, in advance, to have EOL discussions with their patients. The DNR order is often the first step in the decision to withhold other measures (e.g. dialysis, mechanical ventilation, vasopressor therapy) and may shift care from supportive to palliative.
3. Resuscitation Cardiac arrest from all causes prior to 1960 was treated by open chest massage via a thoracotomy. In 1960 Knickerbocker and his colleagues, (after multiple animal experiments), theorized that performing closed chest massage, where the heart being compressed against the vertebral column, would provide effective circulation.4 They conducted a study on twenty patients who had sustained cardiac arrest, mostly in the perioperative period. Closed Cardiopulmonary Resuscitation (CPR) was highly successful in that 70% of these patients were discharged from the hospital neurologically intact. Based on their research they stated “Anyone anywhere can initiate cardiac resuscitative procedures. All that is needed are two hands”. This was the advent of modern CPR. Their results were clearly skewed compared to current data for in hospital cardiac arrests as most of their patients were relatively young with healthy hearts and had witnessed arrests in the perioperative period related to hypoxemia and other easily reversible conditions with immediate care at hand. Based on data from this study, patients began to be routinely resuscitated after cardiac arrests from all causes. This resulted in relatively unhealthy patients undergoing CPR. Overtime, clinicians noted the results were not as robust and began to question the practice of providing CPR to all patients especially in cases where they felt there was poor QOL after CPR. Physicians began to independently discontinue life support (e.g. mechanical ventilation) without patient or surrogate involvement in the decision. This paternalistic approach of physicians to not provide CPR to patients who they thought were poor candidates garnered media attention and as such a Presidential Commission on medical ethics was formed to evaluate this and other EOL issues.5 The institution of the DNR order was the outcome of this commission’s report.
5. Perioperative DNR orders The Omnibus Reconciliation Act of 1990 made it mandatory for hospitals accepting Medicare or Medicaid dollars to discuss advance directives with patients.6 This mandate did not require a physician to initiate the discussion. In an ideal world, however, the primary care physician would do so. Unfortunately, this frequently does not occur. Prior to 1990, the policy for patients undergoing surgery was an automatic rescinding of the DNR order. There were multiple thought processes behind this, ranging from concern that anesthesia or the procedure might precipitate an arrest and as such would be easily reversible. Also there seemed to be the sentiment that there was a moral obligation to resuscitate all patients undergoing surgery. Physicians began to question this automatic rescinding of the DNR order as it appeared to violate patient autonomy.7–9 One author suggested that the perioperative DNR order be automatically maintained during surgery. This was based on five reasons: 1) where else are you more likely to have a cardiac arrest than the OR? 2) patients accept their mortality 3) patients like the idea of dying under anesthesia as a peaceful end 4) It is similar to withholding blood transfusion for a Jehovah’s Witness patient: and 5) the “double effect” applies.10 This reasoning, however, is unfounded based on the following: 1) Survival from a cardiac arrest in the operating room is 10–20 times more likely than in other parts of the hospital.11 2) Patients do accept their mortality but do not expect to die during surgery. They expect the procedure to improve their QOL. 3) The concept of a patient dying peacefully while under anesthesia comes dangerously close to suggesting physician-assisted death and most physicians and state laws are not compatible with that mode of reasoning. 4) A comparison of a DNR order to an order to not transfuse a Jehovah’s Witness patient is not accurate because the act of transfusing a Jehovah’s Witness blood is an irrevocable act, while performing CPR after an arrest in the operating room still has the” safety net” of being able to withdraw death delaying therapies (e.g. mechanical ventilation, vasopressors). 5) The “double effect” deals with intent. It is medically, ethically, legally, and morally accepted, meaning that if your intent is to do good and something bad happens, it is justified. An example of the double effect would be administering morphine to ease shortness of breath to a patient in respiratory failure who does not wish to undergo mechanical ventilation. Were the patient to develop apnea this would be acceptable provided that the intent was to ease suffering, not commit physician aided death. Most professional societies have adopted the policy of “required reconsideration” as it pertains to a perioperative DNR order.9 This requires that the caring physicians must discuss the preexisting DNR order and establish with the patient goals and options related to resuscitation prior to surgery. Based on these discussions the patient may choose to rescind the DNR order during the perioperative period, which is what is most recommended by anesthesiologists and surgeons, or the patient may opt to have the DNR order maintained. This, however, is contingent on the willingness of the physicians involved in the procedure to allow a patient to expire should cardiac arrest occur in the OR. In an ideal situation, this discussion should take place well before the patient arrives in the preoperative area with the patient’s primary care
4. The DNR order: application and interpretation The DNR order should only be applied in situations of QOL or futility. The patient or his surrogate, not the physician, is primarily responsible for making decisions related to QOL. It is solely based on what the patient or his/her surrogate perceives their QOL to be after suffering a cardiac arrest. As an example a patient presenting for surgery to resect a cancerous tumor may decide that he/she does not think his/her long term QOL is viable if he/she were to suffer cardiac arrest, in and may opt therefore to have a perioperative DNR order enacted. Futility of care however is a decision for the physician to make based on his/her knowledge of the patient’s disease process. Decisions regarding futility of CPR should be evidence-based; detailing what underlying medical conditions would prevent CPR from being effective. Therapy that would be medically futile has often been defined as one that would have < 1% chance of being effective. As an example, a physician treating a patient with metastatic cancer and heart failure could decide not to offer CPR based on survival rates in this situation of near 0% and as such, could independently enact a DNR order. Physicians need to take responsibility for decisions regarding futility of care. Frequently decisions to make a person DNR are made after discussions with the family because the patient is not in a position to do so. Asking the family “what do you want to do” regarding decision to withhold CPR in the setting of futility is detrimental and abdicates physician responsibility. Rather, physicians should opt for phrases such as “under these circumstances we will do what we can to keep your loved one from having their heart stop, but in the event that this occurs we are not going to perform CPR as it will only prolong your loved one’s suffering”. This approach can help ease the burden of guilt on the family or surrogate to make such a decision. Of course, exceptions based on religious or other personal beliefs may need to be taken into account. 10
Perioperative Care and Operating Room Management 9 (2017) 9–11
A. Rajagopal, D.M. Rothenberg
physician’s being involved. 6.
References
7. 1. Mill John Stuart. On Liberty. New York: Dover Publications; 2002:65. 2. Schloendorff V. Society of New York Hospital. 105 N.E. 92 (N.Y. 1914); 1914. 3. Salgo V. Leland Stanford Jr. Univ. Bd. Trustees. 154 Cal. App. 2d 560, 317 P.2d 170; 1957. 4. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960;173:1064–1067. 5. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment:
8. 9. 10. 11.
11
Ethical, Medical, and Legal Issues in Treatment Decisions. Washington, DC: Government Printing Office; 1983. Omnibus Reconciliation Act. Title IV. Section 4206. Congressional Record, October 26, 2990, 1, 2638, 1990. Truog RD. “Do-not-resuscitate” orders during anesthesia and surgery. Anesthesiology. 1991;74:606–608. Franklin CM, Rothenberg DM. “Do-not-resuscitate” orders in the presurgical patient. J Clin Anest. 1992;4:181–184. Cohen CB, Cohen PJ. “Do-not-resuscitate” orders in the operating room. N Engl J Med. 1991;325:1879–1882. Walker RM. DNR in the OR – resuscitation as an operative risk. JAMA. 1991;266:2407–2412. O’Connor CJ. Intraoperative cardiac arrest. Anesthesiol Clin. 1995;13(4):905–922.
Contents lists available at ScienceDirect
Perioperative Care and Operating Room Management journal homepage: www.elsevier.com/locate/pcorm
Understanding the perioperative do-not-resuscitate order☆ ⁎
T
Arvind Rajagopal , David M. Rothenberg Rush University, 1653 West Congress Pkwy, Chicago, IL 60612, United States
A B S T R A C T The primary goal of this article is to improve end-of-life (EOL) care in the perioperative period. Clinicians should be able to understand the ethical and legal foundations for the “do-not-resuscitate” (DNR) order to help patients and their families make decisions about EOL care, understand the concept of “required reconsideration” for DNR orders prior to surgical procedures, acknowledge that DNR orders are based either on the patient’s perception of their quality of life (QOL) or the physician’s determination of medical futility as it relates to the patient’s disease process, and appreciate the distinction between prolonging life and prolonging death in the perioperative setting.
1. Principles of medical ethics The main tenets of medical ethics are based on beneficence, nonmaleficence, social justice and autonomy. Beneficence, or “doing good”, should be determined from the patient’s perspective and therefore may differ from the physician’s point of view. Nonmaleficence, or “do no harm”, may include therapies which may attempt to prolong life (e.g. mechanical ventilation, extra corporeal membrane oxygenation) but in reality may be merely prolonging death. Social justice is often not practiced on an individual patient level, but is increasingly becoming an issue as the costs of health care continue to escalate. This comes into play when we resuscitate a patient and admit the patient to an intensive care unit on life support, who because of a lack of a DNR order now has had death prolonged and utilizes a service (i.e. critical care) that might otherwise have benefited a patient whose life might be prolonged. This is frequently the cause of excessive costs in medicine at the EOL. Finally, autonomy relates to the patient’s right to make decisions for themselves. John Stuart Mill gave the basis for autonomy in his 1840 treatise, “On Liberty” when he stated: “considerations to aid man’s judgement, exhortations to strengthen his will, can be offered to him, even obtruded upon him by others, but he himself makes the final judgement”.1 The foundation of the DNR order is based on this ethical principle of autonomy and also on the legal principle of informed consent. 2. Informed consent A landmark case Schloendorff versus Society of New York Hospital
☆ ⁎
illustrated the importance of informed consent.2 The patient sued the hospital for having undergone a surgical procedure when she had only consented to having a gynecologic exam under anesthesia. Judge Benjamin Cardozo, who ruled for the plaintiff, wrote: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages. This is true except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained.” While this future U.S. Supreme Court Justice had ruled for the plaintiff, no damages were awarded as the patient had sued the hospital but not the physicians. The hospital was declared immune because of “charitable immunity”. This was known as Schloendorff’s law and applied to non-profit hospitals until it was overturned in 1957 in another landmark case, Salgo vs. Leland Stanford Hospital Jr. University Board of Trustees.3 This case emphasized the aspect of the “informed” portion of “informed consent. The patient underwent translumbar aortography which resulted in lower extremity paralysis as a complication related to the procedure. The patient sued based on both the claim of medical negligence as well as on the claim of failure to disclose all possible complications of the procedure. The court found that physicians had a duty to disclose ”any facts which are necessary to form the basis of an intelligent consent by the patient to a proposed treatment”. This case highlighted the need for all pertinent topics of consent such as the nature, consequences, harms, benefits, risks and alternatives of a
Based on a presentation given at the 12th Annual Perioperative Medicine Summit (March 11, 2017), Fort Lauderdale, FL. Corresponding author. E-mail address: [email protected] (A. Rajagopal).
https://doi.org/10.1016/j.pcorm.2017.11.009 Received 3 October 2017; Accepted 2 November 2017 Available online 06 November 2017 2405-6030/ © 2017 Elsevier Inc. All rights reserved.
Perioperative Care and Operating Room Management 9 (2017) 9–11
A. Rajagopal, D.M. Rothenberg
treatment, to be discussed with the patient to make a truly “informed consent”.
In essence, the DNR order is purely a nursing order. It is unique in that it actually directs clinicians to not do something and applies to CPR only. Interpretation of the DNR order by physicians has been varied over the years. Physicians have on occasion been known to perform what has been called a “slow” or “show” code. This paternalistic approach of physicians would constitute a violation of medical ethics and should be avoided. This is used by physicians who have failed, in advance, to have EOL discussions with their patients. The DNR order is often the first step in the decision to withhold other measures (e.g. dialysis, mechanical ventilation, vasopressor therapy) and may shift care from supportive to palliative.
3. Resuscitation Cardiac arrest from all causes prior to 1960 was treated by open chest massage via a thoracotomy. In 1960 Knickerbocker and his colleagues, (after multiple animal experiments), theorized that performing closed chest massage, where the heart being compressed against the vertebral column, would provide effective circulation.4 They conducted a study on twenty patients who had sustained cardiac arrest, mostly in the perioperative period. Closed Cardiopulmonary Resuscitation (CPR) was highly successful in that 70% of these patients were discharged from the hospital neurologically intact. Based on their research they stated “Anyone anywhere can initiate cardiac resuscitative procedures. All that is needed are two hands”. This was the advent of modern CPR. Their results were clearly skewed compared to current data for in hospital cardiac arrests as most of their patients were relatively young with healthy hearts and had witnessed arrests in the perioperative period related to hypoxemia and other easily reversible conditions with immediate care at hand. Based on data from this study, patients began to be routinely resuscitated after cardiac arrests from all causes. This resulted in relatively unhealthy patients undergoing CPR. Overtime, clinicians noted the results were not as robust and began to question the practice of providing CPR to all patients especially in cases where they felt there was poor QOL after CPR. Physicians began to independently discontinue life support (e.g. mechanical ventilation) without patient or surrogate involvement in the decision. This paternalistic approach of physicians to not provide CPR to patients who they thought were poor candidates garnered media attention and as such a Presidential Commission on medical ethics was formed to evaluate this and other EOL issues.5 The institution of the DNR order was the outcome of this commission’s report.
5. Perioperative DNR orders The Omnibus Reconciliation Act of 1990 made it mandatory for hospitals accepting Medicare or Medicaid dollars to discuss advance directives with patients.6 This mandate did not require a physician to initiate the discussion. In an ideal world, however, the primary care physician would do so. Unfortunately, this frequently does not occur. Prior to 1990, the policy for patients undergoing surgery was an automatic rescinding of the DNR order. There were multiple thought processes behind this, ranging from concern that anesthesia or the procedure might precipitate an arrest and as such would be easily reversible. Also there seemed to be the sentiment that there was a moral obligation to resuscitate all patients undergoing surgery. Physicians began to question this automatic rescinding of the DNR order as it appeared to violate patient autonomy.7–9 One author suggested that the perioperative DNR order be automatically maintained during surgery. This was based on five reasons: 1) where else are you more likely to have a cardiac arrest than the OR? 2) patients accept their mortality 3) patients like the idea of dying under anesthesia as a peaceful end 4) It is similar to withholding blood transfusion for a Jehovah’s Witness patient: and 5) the “double effect” applies.10 This reasoning, however, is unfounded based on the following: 1) Survival from a cardiac arrest in the operating room is 10–20 times more likely than in other parts of the hospital.11 2) Patients do accept their mortality but do not expect to die during surgery. They expect the procedure to improve their QOL. 3) The concept of a patient dying peacefully while under anesthesia comes dangerously close to suggesting physician-assisted death and most physicians and state laws are not compatible with that mode of reasoning. 4) A comparison of a DNR order to an order to not transfuse a Jehovah’s Witness patient is not accurate because the act of transfusing a Jehovah’s Witness blood is an irrevocable act, while performing CPR after an arrest in the operating room still has the” safety net” of being able to withdraw death delaying therapies (e.g. mechanical ventilation, vasopressors). 5) The “double effect” deals with intent. It is medically, ethically, legally, and morally accepted, meaning that if your intent is to do good and something bad happens, it is justified. An example of the double effect would be administering morphine to ease shortness of breath to a patient in respiratory failure who does not wish to undergo mechanical ventilation. Were the patient to develop apnea this would be acceptable provided that the intent was to ease suffering, not commit physician aided death. Most professional societies have adopted the policy of “required reconsideration” as it pertains to a perioperative DNR order.9 This requires that the caring physicians must discuss the preexisting DNR order and establish with the patient goals and options related to resuscitation prior to surgery. Based on these discussions the patient may choose to rescind the DNR order during the perioperative period, which is what is most recommended by anesthesiologists and surgeons, or the patient may opt to have the DNR order maintained. This, however, is contingent on the willingness of the physicians involved in the procedure to allow a patient to expire should cardiac arrest occur in the OR. In an ideal situation, this discussion should take place well before the patient arrives in the preoperative area with the patient’s primary care
4. The DNR order: application and interpretation The DNR order should only be applied in situations of QOL or futility. The patient or his surrogate, not the physician, is primarily responsible for making decisions related to QOL. It is solely based on what the patient or his/her surrogate perceives their QOL to be after suffering a cardiac arrest. As an example a patient presenting for surgery to resect a cancerous tumor may decide that he/she does not think his/her long term QOL is viable if he/she were to suffer cardiac arrest, in and may opt therefore to have a perioperative DNR order enacted. Futility of care however is a decision for the physician to make based on his/her knowledge of the patient’s disease process. Decisions regarding futility of CPR should be evidence-based; detailing what underlying medical conditions would prevent CPR from being effective. Therapy that would be medically futile has often been defined as one that would have < 1% chance of being effective. As an example, a physician treating a patient with metastatic cancer and heart failure could decide not to offer CPR based on survival rates in this situation of near 0% and as such, could independently enact a DNR order. Physicians need to take responsibility for decisions regarding futility of care. Frequently decisions to make a person DNR are made after discussions with the family because the patient is not in a position to do so. Asking the family “what do you want to do” regarding decision to withhold CPR in the setting of futility is detrimental and abdicates physician responsibility. Rather, physicians should opt for phrases such as “under these circumstances we will do what we can to keep your loved one from having their heart stop, but in the event that this occurs we are not going to perform CPR as it will only prolong your loved one’s suffering”. This approach can help ease the burden of guilt on the family or surrogate to make such a decision. Of course, exceptions based on religious or other personal beliefs may need to be taken into account. 10
Perioperative Care and Operating Room Management 9 (2017) 9–11
A. Rajagopal, D.M. Rothenberg
physician’s being involved. 6.
References
7. 1. Mill John Stuart. On Liberty. New York: Dover Publications; 2002:65. 2. Schloendorff V. Society of New York Hospital. 105 N.E. 92 (N.Y. 1914); 1914. 3. Salgo V. Leland Stanford Jr. Univ. Bd. Trustees. 154 Cal. App. 2d 560, 317 P.2d 170; 1957. 4. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960;173:1064–1067. 5. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment:
8. 9. 10. 11.
11
Ethical, Medical, and Legal Issues in Treatment Decisions. Washington, DC: Government Printing Office; 1983. Omnibus Reconciliation Act. Title IV. Section 4206. Congressional Record, October 26, 2990, 1, 2638, 1990. Truog RD. “Do-not-resuscitate” orders during anesthesia and surgery. Anesthesiology. 1991;74:606–608. Franklin CM, Rothenberg DM. “Do-not-resuscitate” orders in the presurgical patient. J Clin Anest. 1992;4:181–184. Cohen CB, Cohen PJ. “Do-not-resuscitate” orders in the operating room. N Engl J Med. 1991;325:1879–1882. Walker RM. DNR in the OR – resuscitation as an operative risk. JAMA. 1991;266:2407–2412. O’Connor CJ. Intraoperative cardiac arrest. Anesthesiol Clin. 1995;13(4):905–922.