DNR IN THE OR Tia Powell, MD Director, Montefiore-Einstein Center for Bioethics
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DNR IN THE OR
Tia Powell, MDDirector,
Montefiore-EinsteinCenter for Bioethics
THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.
Leading change. Improving care for older adults.
AGS
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Thomas Eakins
Gross Clinic
1875
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DNR IN THE OR: SOURCE OF ETHICAL CONTROVERSY
• Surgery and anesthesia require components of resuscitation
• Increased risk of iatrogenic cardiac arrest
• Is surgeon responsible for OR death of patient with DNR order?
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HISTORY OF RESUSCITATION: PULMONARY (1 of 3)
• Old Testament, Book of Kings: Prophet Elisha restores life by breathing into mouth of child
• Paracelsus, 1500s: fireside bellows restore breathing
• Vesalius, 1540: opens trachea and restores life to animal via reed tube
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HISTORY OF RESUSCITATION: PULMONARY (2 of 3)
Setback/misunderstanding in 1770s:
• Discovery of oxygen and relevance to respiration
• Discredits use of exhaled air as aid to respiration
• Exhaled air not used to aid respiration again until 1950s
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HISTORY OF RESUSCITATION: PULMONARY (3 of 3)
• Polio: negative pressure ventilator (“iron lung”)
• 1952: polio epidemic, lack of vents
• Danish medical students assigned to manually vent via trach tube
• Adoption of positive pressure vent
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HISTORY OF RESUSCITATION: CARDIAC
• Closed-chest pressure used in 1850s, viewed as aid to respiration
• 1901: open-chest cardiac massage reverses chloroform-induced arrest
• 1958: closed-chest compression rediscovered in treatment of cardiac arrest
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HISTORY OF RESUSCITATION: DEFIBRILLATION (1 of 2)
“Abildgard . . . in 1775 . . . shocked a single chicken into lifelessness and upon repeating the shock, the bird took off and eluded further experimentation.”
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HISTORY OF RESUSCITATION: DEFIBRILLATION (2 of 2)
• 1933: closed-chest defibrillation as treatment for electrocution
• 1947: first human open-chest defibrillation(14-year-old boy, intra-op arrest)
• 1955: first closed-chest defibrillation
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MODERN RESUSCITATION
• 1960s: CPR guidelines, ABCs
• 1970s: Public campaigns for out-of-hospital CPR
• Survival rates after CPR: In hospital: 15% Out of hospital: 6%
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HISTORY OF DNR ORDERS:NEW YORK
1982: Queens hospital investigated for use of unwritten DNR orders• Code status decided secretly by doctors• No consultation with patient, family• Purple dots
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DNR LEGISLATION:NEW YORK
• Shaped by scandal
• Emphasis on consent
• Presumption of consent to resuscitation unless DNR order exists
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INITIAL REACTION TO DNR LAW
• Will kill patients by discussing DNR Commissioner Daines
• Will force doctors to resuscitate patients in rigor mortis
Urban legend
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DNR IN OR• Remains controversial
• Highly variant across country
• Focus of policy in 1990s
• Variation between policy and practice
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AMERICAN COLLEGE OF SURGEONS, 1994 (1 of 2)
“Policies that lead either to the automatic . . . cancellation of [DNR] orders during the operation and recovery period may not address a patient's right to self-determination. An institutional policy of automatic cancellation of the DNR status . . . removes the patient from appropriate participation in decision making.”
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AMERICAN COLLEGE OF SURGEONS, 1994 (2 of 2)
“The best approach is a policy of ‘required reconsideration’ of previous advance directives. The patient and the physicians . . . should discuss the new risks and the approach to potential life-threatening problems during the perioperative period. The results of such discussions should be documented in the record.”
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AMERICAN SOCIETY OF ANESTHESIOLOGY (1 of 2)
“ . . . Any existing directives to limit the use of resuscitation procedures (that is, do-not-resuscitate orders and/or advance directives) should, when possible, be reviewed with the patient or designated surrogate.”
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AMERICAN SOCIETY OF ANESTHESIOLOGY (2 of 2)
3 options:• Full attempt at resuscitation• Limited attempt related to specific procedures• Limited attempt related to patient’s goals
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VETERANS HEALTH ADMINISTRATION POLICY
• It is permissible to suspend a patient’s DNR order for surgery, but only after the practitioner has had a discussion with the patient or surrogate and obtained that person’s consent
• It is never ethically permissible to automatically suspend DNR orders for surgery
• Giving patients the option of having their DNR orders suspended for surgery preserves their right to make decisions consistent with their values and health care goals
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POLICY OPTION
DNR form includes section for patients undergoing procedures:
• The patient wishes to revoke DNR To be reinstated X hours post-op
• The patient wishes to maintain DNR status and/or forego X resuscitation procedures
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MONTEFIORE MEDICAL CENTER POLICY FOR DNR IN OR
• Physicians must discuss with patient or surrogate whether existing DNR order should be suspended and if so, specify duration
• Surgeon, anesthesiologist, and patient or surrogate must agree
• Document decision
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POLICY/PRACTICE GAP
• 19-page DNR policy
• Concern over iatrogenic arrest
• Concern over mortality statistics
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OR MORTALITY AND DNR• NY State, Montefiore Medical Center do not
collect statistics on operative mortality for surgery
• Except: Cardiothoracic surgeons have strong regulatory burden
• Could consider risk adjustment for cardio-thoracic surgery
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DISCUSSION• Non-coercive
• Patient goals
• Risk of anesthesia, surgery
• Better resuscitation statistics intra-op
• Options
• If full code, timing of reinstated DNR
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CONCLUSION• DNR order based on consent
• DNR exists in OR
• Challenging in OR
• Requires discussion
• Requires alignment between policy and practice
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