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MODEL POLICY FOR THE PERIOPERATIVE OR PERI-PROCEDURAL TREATMENT OF PATIENTS WITH AN EXISTING DO-NOTRESUSCITATE ORDER OR OTHER DIRECTIVES THAT MAY LIMIT TREATMENT DURING INVASIVE PROCEDURES I. PURPOSE

• To provide guidelines for addressing and respecting patients’ rights to make decisions about the application of resuscitation efforts during the perioperative or periprocedural period • To include in the process of obtaining informed consent a discussion of the feasibility of withholding resuscitation during the perioperative or periprocedural period • To address the need to respect physicians’ professional integrity while honoring patients’ right of self-determination

II. BACKGROUND

Per Health Care Decisions Law, Probate Code Section 4650 (the Patient Self-Determination Act passed in 1990): “in recognition of the dignity and privacy a person has a right to expect, the law recognizes that an adult has the fundamental right to control the decisions relating to his or her own health care, including the decision to have life-sustaining treatment withheld or withdrawn.” This federal legislation was designed to ensure patient self-determination for decisions about health care, including decisions about life-sustaining therapy. Patients have the right to execute advance directives and have them honored. However, for patients with an existing DNR order, it is a frequent occurrence – in some cases routine – to automatically suspend this order during the periprocedural period. At times, patients have been asked to choose between allowing resuscitation during surgery or the procedure, or forgoing the surgery or procedure. The application of a DNR order during surgery can be problematic for several reasons: 1. General anesthesia itself involves procedures often indistinguishable from resuscitative efforts. 2. The anesthetic agents themselves may produce adverse physiologic effects including respiratory depression, cardiovascular dysfunction, or even cardiac arrest. These adverse effects may be quickly and easily reversible. 3. In the case of invasive cardiac surgeries, arrhythmias including asystole can be after surgery. 4. Surgery itself may produce adverse effects, such as blood and fluid loss or pathophysiological reflexes that often are quickly and easily reversible. It is standard practice, prior to any invasive procedure, to discuss with the patient and/or surrogate decision-maker the potential risks and benefits inherent in the procedure. This informed consent process should include a discussion of whether to continue or to suspend an existing DNR order during the peri-surgical/procedural period and the duration of the suspension. Without informed refusal there cannot be informed consent.

III. POTENTIAL OPTIONS

The “Ethical Guidelines for the Anesthesia Care of Patients with DoNot-Resuscitate Orders or Other Directives That Limit Treatment” adopted by the American Society of Anesthesiologists in 1993, with similar policies adopted shortly thereafter by the American College of Surgeons and by the Association of Operating Room Nurses, recommends a required reconsideration and renegotiation of a patient’s existing DNAR directive. Three options have evolved for patients about to undergo surgery or a pro-

cedure to consider: A. “Full Attempt at Resuscitation: The patient or designated surrogate may request the full suspension of existing DNR directives during the anesthetic and immediate postoperative period, thereby consenting to the use of any resuscitation procedures that may be appropriate to treat clinical events that occur during this time. B. Limited Attempt at Resuscitation Defined With Regard to Specific Procedures: The patient or designated surrogate may elect to continue to refuse certain specific resuscitation procedures (for example, chest compression, defibrillation or tracheal intubation). The anesthesiologist should inform the patient or designated surrogate about which anesthetic resuscitative management procedures are 1) essential to the success of the anesthesia and 2) which are not and may be refused. The same applies to the surgeon or proceduralist. C. Limited Attempt at Resuscitation Defined With Regard to the Patient’s Goals and Values: The patient or designated surrogate may allow the anesthesiologist, surgeon, or proceduralist to use clinical judgment in determining which resuscitation procedures are appropriate in the context of the situation and consistent with the patient’s stated goals and values. For example, some patients may want full resuscitation procedures to be used to manage adverse clinical events that are believed to be quickly and easily reversible, but to refrain from treatments that are likely to result in permanent sequelae, such as neurologic impairment or unwanted dependence upon life-sustaining technology.”

IV. POLICY STATEMENT

It is the policy of this institution to provide patients and/or their surrogate-decision-maker a detailed description of the proposed procedure along with the potential risks and benefits that may be involved. Included in this discussion should be determining the patient’s wishes with regard to resuscitation during the perioperative period. If the patient/surrogate chooses to suspend or modify the existing DNR orders, a time frame should be defined for this suspension. The process of informed consent is not complete until the patient/surrogate understands and agrees to a specific course of action. This discussion must be documented in the chart. All patients and all anesthetics, surgeries and procedures are unique: the above discussion needs to be tailored to the circumstances at hand. Examples of differing circumstances with differing goals include: • SPECIAL CONSIDERATION: PATIENTS WITH A DIAGNOSIS OF A TERMINAL CONDITION CONSIDERING PALLIATIVE SURGERY These are patients with a limited prognosis from their underlying disease, who are hoping to increase the quality of their remaining time by surgical intervention. It may be difficult to distinguish whether adverse effects happening in the operating room or procedural suite are a consequence of the surgery and/ or anesthesia or are a consequence of the underlying disease. Understanding the goals and values of these patients, likely focusing on quality rather than quantity of life, might allow a

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