Use of Advance Directives for High-Risk Operations

Redmann, Andrew J.; Brasel, Karen J.; Alexander, Caleb; Schwarze, Margaret L.

doi:10.1097/sla.0b013e31823b6782

Cited by 78 publications

(26 citation statements)

References 21 publications

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“…[27] In a survey of 2,100 surgeons practicing in the U.S., the majority reported refusing to operate on patients with preferences for limiting life support and only half considered it acceptable to honor a patient or surrogate request to withdraw life support on postoperative Day 7. [28, 29] In our study cohort, limiting life support postoperatively in the SICU also may have been viewed as undesirable if physicians viewed ALI as an avoidable complication. [30] However, for patients who remained critically ill for at least a week, the rate of limitations in life support in a SICU vs MICU was not significantly different.…”

Section: Discussionmentioning

confidence: 99%

Timing of Limitations in Life Support in Acute Lung Injury Patients

Turnbull

Ruhl

Lau

et al. 2014

Critical Care Medicine

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Objective Substantial variability exists in the timing of limitations in life support for critically ill patients. Our objective was to investigate how the timing of limitations in life support varies with changes in organ failure status and time since acute lung injury (ALI) onset. Design, Setting, and Patients This evaluation was performed as part of a prospective cohort study evaluating 490 consecutive ALI patients recruited from 11 intensive care units (ICUs) at three teaching hospitals in Baltimore, MD. Interventions None. Measurements The primary exposure was proportion of days without improvement in Sequential Organ Failure Assessment (SOFA) score, evaluated as a daily time-varying exposure. The outcome of interest was a documented limitation in life support defined as any of the following: (1) No CPR, (2) Do not re-intubate, (3) No vasopressors, (4) No hemodialysis, (5) Do not escalate care or (6) Other limitation (e.g., “comfort care only”). Main Results For medical ICU (MICU) patients without improvement in daily SOFA score, the rate of limitation in life support tripled in the first three days after ALI onset, increased again after Day 5, and peaked at Day 19. Compared to MICU patients, surgical ICU (SICU) patients had a rate of limitations that was significantly lower during the first five days after ALI onset. In all patients, more days without improvement in SOFA scores was associated with limitations in life support, independent of the absolute magnitude of the SOFA score. Conclusions Persistent organ failure is associated with an increase in the rate of limitations in life support independent of the absolute magnitude of SOFA score, and this association strengthens during the first weeks of treatment. During the first five days after ALI onset limitations were significantly more common in MICUs than SICUs.

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Section: Discussionmentioning

confidence: 99%

Timing of Limitations in Life Support in Acute Lung Injury Patients

Turnbull

Ruhl

Lau

et al. 2014

Critical Care Medicine

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“…Almost half (47%) of those doctors we surveyed agreed that DNR status should be suspended due to the increased likelihood of successful resuscitation in the OR environment. Although our survey did not assess whether doctors would forego offering surgical care to patients who refused to suspend their DNR orders perioperatively, a recent study reported that 54% of surgeons queried would refuse to operate on patients whose directives placed limits on postoperative care [25]. Since it may at times be difficult to distinguish between cardiopulmonary arrest and iatrogenic (anesthesia-related) depression of vital organs, some providers find it difficult to follow a patient’s DNR status intraoperatively [5,9].…”

Section: Discussionmentioning

confidence: 99%

Patient and doctor attitudes and beliefs concerning perioperative do not resuscitate orders: anesthesiologists’ growing compliance with patient autonomy and self determination guidelines

et al. 2013

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BackgroundIn 1993, the American Society of Anesthesiologists (ASA) published guidelines stating that automatic perioperative suspension of Do Not Resuscitate (DNR) orders conflicts with patients’ rights to self-determination. Almost 20 years later, we aimed to explore both patient and doctor views concerning perioperative DNR status.MethodsFive-hundred consecutive patients visiting our preoperative evaluation clinic were surveyed and asked whether they had made decisions regarding resuscitation and to rate their agreement with several statements concerning perioperative resuscitation. Anesthesiologists, surgeons and internists at our tertiary referral institution were also surveyed. They were asked to assess their likelihood of following a hypothetical patient’s DNR status and to rate their level of agreement with a series of non-scenario related statements concerning ethical and practical aspects of perioperative resuscitation.ResultsOver half of patients (57%) agreed that pre-existing DNR requests should be suspended while undergoing a surgical procedure under anesthesia, but 92% believed a discussion between the doctor and patient regarding perioperative resuscitation plans should still occur. Thirty percent of doctors completing the survey believed that DNR orders should automatically be suspended intraoperatively. Anesthesiologists (18%) were significantly less likely to suspend DNR orders than surgeons (38%) or internists (34%) (p < 0.01).ConclusionsAlthough many patients agree that their DNR orders should be suspended for their operation, they expect a discussion regarding the performance and nature of perioperative resuscitation. In contrast to previous studies, anesthesiologists were least likely to automatically suspend a DNR order.

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“…Our findings about surgeon reported conflict with intensivists underscore how important it is for patients to discuss their goals and values with their surgeon and surrogate decision makers preoperatively in order to inform postoperative decisions in the event of an undesired outcome. 15,16,24,25 Patients and their surrogates can be referred to other available resources for conflict adjudication to help guide treatment decisions such as a second opinion from a panel of senior clinicians or the hospital ethics committee. 3,9,13,21,23,26,27 …”

Section: Commentsmentioning

confidence: 99%

Surgeon-Reported Conflict With Intensivists About Postoperative Goals of Care

et al. 2013

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Objective To examine surgeons’ experiences of conflict with intensivists and nurses about goals of care for their postoperative patients. Design Cross-sectional incentivized U.S. mail-based survey. Setting Private and academic surgical practices. Participants 2,100 vascular, neurological, and cardiothoracic surgeons. Main Outcome Measures Surgeon-reported rates of conflict with intensivists and nurses about goals of care in patients with poor post-surgical outcomes. Results The adjusted response rate was 55.6%. Forty-three percent of surgeons report sometimes or always experiencing conflict about postoperative goals of care with intensivists, and 43% report conflict with nurses. Younger surgeons report higher rates of conflict than older surgeons with both intensivists (57 vs. 32%, p=0.001) and nurses (48 vs. 33%, p=0.001). Surgeons practicing in closed ICUs report more frequent conflict than those practicing in open ICUs (60 vs. 41% p=0.005). On multivariate analysis, the odds of reporting conflict with intensivists were 2.5 times higher for surgeons with fewer years of experience as compared to their older colleagues (OR: 2.5, 95% CI: 1.6-3.8) and 70% higher for reporting conflict with nurses (OR: 1.7, 95% CI: 1.1-2.6). The odds of reporting conflict with intensivists about goals of postoperative care were 40% lower for surgeons who primarily manage their ICU patients than for those who work in a closed unit (OR: 0.6, 95% CI: 0.4-0.96). Conclusions Surgeons regularly experience conflict with critical care clinicians about goals of care for patients with poor postoperative outcomes. Higher rates of conflict are associated with less experience and working in a closed ICU.

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Use of Advance Directives for High-Risk Operations

Cited by 78 publications

References 21 publications

Timing of Limitations in Life Support in Acute Lung Injury Patients

Timing of Limitations in Life Support in Acute Lung Injury Patients

Patient and doctor attitudes and beliefs concerning perioperative do not resuscitate orders: anesthesiologists’ growing compliance with patient autonomy and self determination guidelines

Surgeon-Reported Conflict With Intensivists About Postoperative Goals of Care

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