The first step when encountering this scenario is to ensure that the procedure is indicated in this particular patient. While guidelines and algorithms have a substantial role in deciding the appropriate work-up for a presenting complaint such as a presumed upper gastrointestinal bleed, the art of medicine lies in the role of the physicians to decide if an invasive procedure is indicated in their specific patients. This decision should be based on the patients’ presenting clinical scenario, their overall comorbidities, their values, and their goals of care.
As the medical complexity of the patient increases, the risks of the procedure increase and it is ultimately up to the endoscopist to frame the informed consent conversation such that the patient and family understand the potential risks and benefits in their specific case.
With a patient who has a desire to avoid aggressive resuscitation attempts, the physician, patient, and family should weigh the risks and benefits of the procedure, and carefully examine if the indication is sufficient. For the patient outlined in the case, her dementia limits her decision-making capacity, and the clinical team is working with a surrogate decision-maker, her POA, to understand the patient’s wishes and goals. Her POA reports upon admission that invasive procedures may not be in line with her previously expressed values or in her best interest. However, with the development of an acute decompensation due to a presumed GI bleed, a potentially reversible cause, the POA requests an endoscopy to attempt to intervene. Occasionally, a patient with clear goals of care can have a change in these goals when a decompensation occurs. The gastroenterologist should assess if this represents a true desire for invasive procedures, or if this is a response to pressure from other members of the clinical team or family, or if palliative needs are not being met. In this patient, her POA desires an endoscopy because her likely upper GI bleed may be contributing to an acute decompensation, but does not wish for other aggressive measures if she should suffer cardiopulmonary arrest. Although upper endoscopy is a generally safe and well-tolerated procedure, this patient’s cardiopulmonary comorbidities increase the risk of the procedure; therefore, the gastroenterology team should proceed with a candid, detailed discussion of risks, benefits, and alternatives with the patient’s POA.
If the decision is made to proceed with endoscopy, the next step is to address the patient’s code status surrounding the procedure. This conversation should focus on three key goals: 1) allow the physician to gain understanding of the patient or surrogate’s perspectives on goals of care; 2) provide the patient or surrogate with an understanding of the risks and potential outcomes of the procedure, as well as resuscitation options; and 3) ultimately arrive at a mutual consensus regarding the patient’s periprocedural code status. Plans for postprocedural care should also be discussed.
While gastroenterology societies do not have specific guidelines surrounding this situation, there are several steps clinicians can take to ensure patient safety and autonomy are preserved:
- Physicians should avoid one-size-fits-all policies, such as the expectation that patients routinely return to full code for procedures.
- The patient and/or decision-makers should have a discussion regarding the risks during the procedure and potential reversibility of these risks.
- The patient should be presented with the option to either reverse to full code, refuse specific resuscitative measures such as defibrillation or intubation, or be allowed to explain his or her own views on goals of care and allow the procedural team to use their clinical judgment should an emergency arise.
- Physicians should be specific regarding the duration of the code status change. For example, in a patient who has reversed the code status to allow a full resuscitation attempt, the team and patient should discuss how long the patient will remain intubated after the procedure.
- This discussion should be documented carefully in the chart to assist with dissemination amongst the medical team.
This process will ensure that clear guidelines are defined such that everyone, including the patient’s potential decision makers, understand to what they are agreeing.
While physicians and care teams are primarily concerned with providing high-quality and individualized care to patients, it is true that concerns surrounding medicolegal risk are present. Careful informed consent and informed refusal conversations will reduce risk. Indeed, in a patient who has a DNR order, physicians are more likely to be at risk performing resuscitation efforts than withholding them. Communication between patients, families, and physicians remains the foundation for a trusting relationship and decreased litigation risk.
For this patient, engaging her POA in an honest and thorough discussion about her goals of care, as well as the risks of both performing and not performing the upper endoscopy are critical to her care. If her POA wishes to proceed with the procedure and have her remain DNR during the procedure, this should be documented and adhered to. Ultimately, the best outcome for this patient will occur with an individualized risk-benefit assessment and open, frequent communication among the care team and her POA.
Dr. Feld is a gastroenterology and hepatology fellow in the department of gastroenterology and hepatology, University of Washington, Seattle. She has no conflicts of interest.
