Original Research

Management of Do Not Resuscitate Orders Before Invasive Procedures

Fed Pract. 2021 February;38(2):80-83 | 10.12788/fp.0088

Author(s):

Background: In 2017, the US Department of Veterans Affairs (VA) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI), which created a portable and durable code status for use across its health care system. Patients who now have a durable do not resuscitate (DNR) status may undergo invasive procedures. Few studies have examined whether proceduralists discuss DNR status and document changes before procedures.

Objective: To assess baseline percentage of suspension of DNR before nonsurgical invasive procedures and determine whether an academic detailing intervention consisting of training proceduralists in the use of a template that allows rapid suspension of DNR status increases percentage of DNR acknowledgments.

Methods: Single-center, quasi-experimental pre- and postassessments were done in high-volume, procedural areas, including gastroenterology, cardiology, and interventional radiology, in a VA medical center. The primary outcome was the proceduralists’ documentation of DNR status acknowledgment before a nonsurgical invasive procedure at baseline and after the intervention. Logistic regression was used to compare percentage of DNR acknowledgment with time (before, after) and procedural area and assessing their interaction in the model.

Results: The interaction between department and time revealed wide variation in documentation of DNR acknowledgment. Examining the model predicted percentages from the interaction, preintervention percentages for gastroenterology, cardiology and interventional radiology were 46%, 75.6%, and 7.5%, respectively, and postintervention model predicted percentages were 53.5%, 91.7%, and 26.3%, respectively. Only the before vs after contrast for interventional radiology was significantly different. When all procedural areas were combined, the percentage of DNR acknowledgment significantly improved from 38.6% to 61.1% ( P = .01).

Conclusions: Before nonsurgical invasive procedures, the percentage of DNR acknowledgment was low but after, the intervention significantly improved. Further research is needed to assess its impact on patient-centered outcomes.

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References

1. Physician Orders for Life-Sustaining Treatment Paradigm. Honoring the wishes of those with serious illness and frailty. Accessed January 11, 2021.

2. Arepally A, Oechsle D, Kirkwood S, Savader S. Safety of conscious sedation in interventional radiology. Cardiovasc Intervent Radiol. 2001;24(3):185-190. doi:10.1007/s002700002549

3. Arrowsmith J, Gertsman B, Fleischer D, Benjamin S. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc. 1991;37(4):421-427. doi:10.1016/s0016-5107(91)70773-6

4. Burkle C, Swetz K, Armstrong M, Keegan M. Patient and doctor attitudes and beliefs concerning perioperative do not resuscitate orders: anesthesiologists’ growing compliance with patient autonomy and self-determination guidelines. BMC Anesthesiol. 2013;13:2. doi:10.1186/1471-2253-13-2

5. American College of Surgeons. Statement on advance directives by patients: “do not resuscitate” in the operative room. Published January 3, 2014. Accessed January 11, 2021. https://bulletin.facs.org/2014/01/statement-on-advance-directives-by-patients-do-not-resuscitate-in-the-operating-room

6. Association of periOperative Registered Nurses. AORN position statement on perioperative care of patients with do-not-resuscitate or allow-natural death orders. Reaffirmed February 2020. Accessed June 16, 2020. https://www.aorn.org/guidelines/clinical-resources/position-statements

7. Bastron DR. Ethical guidelines for the anesthesia care of patients with do-not-resuscitate orders or other directives that limit treatment. Published 1996. Accessed January 11, 2021. https://pubs.asahq.org/anesthesiology/article/85/5/1190/35862/Ethical-Concerns-in-Anesthetic-Care-for-Patients

8. Baxter L, Hancox J, King B, Powell A, Tolley T. Stop! Patients receiving CPR despite valid DNACPR documentation. Eur J Pall Car. 2018;23(3):125-127.

9. Agency for Healthcare Research and Quality. Practice facilitation handbook, module 10: academic detailing as a quality improvement tool. Last reviewed May 2013. Accessed January 11, 2021. 2021. https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod10.html

10. Urman R, Lilley E, Changala M, Lindvall C, Hepner D, Bader A. 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

11. Waisel D, Simon R, Truog R, Baboolal H, Raemer D. Anesthesiologist management of perioperative do-not-resuscitate orders: a simulation-based experiment. Simul Healthc. 2009;4(2):70-76. doi:10.1097/SIH.0b013e31819e137b

12. Lozano P, Finkelstein J, Carey V, et al. A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care. Arch Pediatr Adolesc Med. 2004;158(9):875-883. doi:10.1001/archpedi.158.9.875

13. Brunström M, Ng N, Dahlström J, et al. Association of physician education and feedback on hypertension management with patient blood pressure and hypertension control. JAMA Netw Open. 2020;3(1):e1918625. doi:10.1001/jamanetworkopen.2019.18625

14. Wong J, Duane P, Ingraham N. A case series of patients who were do not resuscitate but underwent cardiopulmonary resuscitation. Resuscitation. 2020;146:145-146. doi:10.1016/j.resuscitation.2019.11.020

15. Mittelberger J, Lo B, Martin D, Uhlmann R. Impact of a procedure-specific do not resuscitate order form on documentation of do not resuscitate orders. Arch Intern Med. 1993;153(2):228-232.

16. Neubauer M, Taniguchi C, Hoverman J. Improving incidence of code status documentation through process and discipline. J Oncol Pract. 2015;11(2):e263-266. doi:10.1200/JOP.2014.001438

In January 2017, the US Department of Veterans Affairs (VA), led by the National Center of Ethics in Health Care, created the Life-Sustaining Treatment Decisions Initiative (LSTDI). The VA gradually implemented the LSTDI in its facilities nationwide. In a format similar to the standardized form of portable medical orders, provider orders for life-sustaining treatments (POLST), the initiative promotes discussions with veterans and encourages but does not require health care professionals (HCPs) to complete a template for documentation (life-sustaining treatment [LST] note) of a patient’s preferences.¹ The HCP enters a code status into the electronic health record (EHR), creating a portable and durable note and order.

With a new durable code status, the HCPs performing these procedures (eg, colonoscopies, coronary catheterization, or percutaneous biopsies) need to acknowledge and can potentially rescind a do not resuscitate (DNR) order. Although the risk of cardiac arrest or intubation is low, all invasive procedures carry these risks to some degree.^2,3 Some HCPs advocate the automatic discontinuation of DNR orders before any procedure, but multiple professional societies recommend that patients be included in these discussions to honor their wishes.^4-7 Although no procedures at the VA require the suspension of a DNR status, it is important to establish which life-sustaining measures are acceptable to patients.

As part of the informed consent process, proceduralists (HCPs who perform a procedure) should discuss the option of temporary suspension of DNR in the periprocedural period and document the outcome of this discussion (eg, rescinded DNR, acknowledgment of continued DNR status). These discussions need to be documented clearly to ensure accurate communication with other HCPs, particularly those caring for the patient postprocedure. Without the documentation, the risk that the patient’s wishes will not be honored is high.⁸ Code status is usually addressed before intubation of general anesthesia; however, nonsurgical procedures have a lower likelihood of DNR acknowledgment.

This study aimed to examine and improve the rate of acknowledgment of DNR status before nonsurgical procedures. We hypothesized that the rate of DNR acknowledgment before nonsurgical invasive procedures is low; and the rate can be raised with an intervention designed to educate proceduralists and improve and simplify this documentation.⁹

Methods

This was a single center, before/after quasi-experimental study. The study was considered clinical operations and institutional review board approval was unnecessary.

A retrospective chart review was performed of patients who underwent an inpatient or outpatient, nonsurgical invasive procedure at the Minneapolis VA Medical Center in Minnesota. The preintervention period was defined as the first 6 months after implementation of the LSTDI between May 8, 2018 and October 31, 2018. The intervention was presented in December 2018 and January 2019. The postintervention period was from February 1, 2019 to April 30, 2019.

Patients who underwent a nonsurgical invasive procedure were reviewed in 3 procedural areas. These areas were chosen based on high patient volumes and the need for rapid patient turnover, including gastroenterology, cardiology, and interventional radiology. An invasive procedure was defined as any procedure requiring patient consent. Those patients who had a completed LST note and who had a DNR order were recorded.

References

1. Physician Orders for Life-Sustaining Treatment Paradigm. Honoring the wishes of those with serious illness and frailty. Accessed January 11, 2021.

2. Arepally A, Oechsle D, Kirkwood S, Savader S. Safety of conscious sedation in interventional radiology. Cardiovasc Intervent Radiol. 2001;24(3):185-190. doi:10.1007/s002700002549

3. Arrowsmith J, Gertsman B, Fleischer D, Benjamin S. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc. 1991;37(4):421-427. doi:10.1016/s0016-5107(91)70773-6

4. Burkle C, Swetz K, Armstrong M, Keegan M. Patient and doctor attitudes and beliefs concerning perioperative do not resuscitate orders: anesthesiologists’ growing compliance with patient autonomy and self-determination guidelines. BMC Anesthesiol. 2013;13:2. doi:10.1186/1471-2253-13-2

5. American College of Surgeons. Statement on advance directives by patients: “do not resuscitate” in the operative room. Published January 3, 2014. Accessed January 11, 2021. https://bulletin.facs.org/2014/01/statement-on-advance-directives-by-patients-do-not-resuscitate-in-the-operating-room

6. Association of periOperative Registered Nurses. AORN position statement on perioperative care of patients with do-not-resuscitate or allow-natural death orders. Reaffirmed February 2020. Accessed June 16, 2020. https://www.aorn.org/guidelines/clinical-resources/position-statements

7. Bastron DR. Ethical guidelines for the anesthesia care of patients with do-not-resuscitate orders or other directives that limit treatment. Published 1996. Accessed January 11, 2021. https://pubs.asahq.org/anesthesiology/article/85/5/1190/35862/Ethical-Concerns-in-Anesthetic-Care-for-Patients

8. Baxter L, Hancox J, King B, Powell A, Tolley T. Stop! Patients receiving CPR despite valid DNACPR documentation. Eur J Pall Car. 2018;23(3):125-127.

9. Agency for Healthcare Research and Quality. Practice facilitation handbook, module 10: academic detailing as a quality improvement tool. Last reviewed May 2013. Accessed January 11, 2021. 2021. https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod10.html

10. Urman R, Lilley E, Changala M, Lindvall C, Hepner D, Bader A. 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

11. Waisel D, Simon R, Truog R, Baboolal H, Raemer D. Anesthesiologist management of perioperative do-not-resuscitate orders: a simulation-based experiment. Simul Healthc. 2009;4(2):70-76. doi:10.1097/SIH.0b013e31819e137b

12. Lozano P, Finkelstein J, Carey V, et al. A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care. Arch Pediatr Adolesc Med. 2004;158(9):875-883. doi:10.1001/archpedi.158.9.875

13. Brunström M, Ng N, Dahlström J, et al. Association of physician education and feedback on hypertension management with patient blood pressure and hypertension control. JAMA Netw Open. 2020;3(1):e1918625. doi:10.1001/jamanetworkopen.2019.18625

14. Wong J, Duane P, Ingraham N. A case series of patients who were do not resuscitate but underwent cardiopulmonary resuscitation. Resuscitation. 2020;146:145-146. doi:10.1016/j.resuscitation.2019.11.020

15. Mittelberger J, Lo B, Martin D, Uhlmann R. Impact of a procedure-specific do not resuscitate order form on documentation of do not resuscitate orders. Arch Intern Med. 1993;153(2):228-232.

16. Neubauer M, Taniguchi C, Hoverman J. Improving incidence of code status documentation through process and discipline. J Oncol Pract. 2015;11(2):e263-266. doi:10.1200/JOP.2014.001438

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Management of Do Not Resuscitate Orders Before Invasive Procedures

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