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Perioperative and DNR

Malgorzata Baumann, Shelley Killebrew, Katherine Zimnicki, Katherine Balint
Do-not-resuscitate (DNR) orders in the perioperative environment must be managed according to national and institutional guidelines. Health care professionals, including perioperative nurses, may be unfamiliar with the guidelines and unsure of their role in reevaluating a DNR order. We conducted a multidisciplinary quality improvement project at a metropolitan community hospital that aimed to improve health care providers' compliance with the institutional policy, nursing involvement in DNR reevaluation, and communication between providers...
July 2017: AORN Journal
Anair Beverly, Ethan Y Brovman, Richard D Urman
PURPOSE: Emergency hip surgery generally has worse outcomes than elective hip surgery, even when adjusted for patient and surgical factors. Do-not-resuscitate (DNR) status patients are typically at higher perioperative risk and undergo a narrow range of surgical procedures. We aimed to compare the outcomes after hip surgery of differing degrees of urgency in this cohort. MATERIALS AND METHODS: Using National Surgical Quality Improvement Program (NSQIP) data, we conducted univariate and multivariate analyses comparing outcomes of DNR status patients after emergency and nonemergency hip surgery (2007-2013)...
June 2017: Geriatric Orthopaedic Surgery & Rehabilitation
Elisa C Walsh, Ethan Y Brovman, Angela M Bader, Richard D Urman
BACKGROUND: Do-not-resuscitate (DNR) orders instruct medical personnel to forego cardiopulmonary resuscitation in the event of cardiopulmonary arrest, but they do not preclude surgical management. Several studies have reported that DNR status is an independent predictor of 30-day mortality; however, the etiology of increased mortality remains unclear. We hypothesized that DNR patients would demonstrate increased postoperative mortality, but not morbidity, relative to non-DNR patients undergoing the same procedures...
November 2017: Anesthesia and Analgesia
William D Sumrall, Elizabeth Mahanna, Vivek Sabharwal, Thomas Marshall
BACKGROUND: Advance directives guide healthcare providers to listen to and respect patients' wishes regarding their right to die in circumstances when cardiopulmonary resuscitation is required, and hospitals accredited by The Joint Commission are required to have a do-not-resuscitate (DNR) policy in place. However, when surgery and anesthesia are necessary for the care of the patient with a DNR order, this advance directive can create ethical dilemmas specifically involving patient autonomy and the physician's responsibility to do no harm...
2016: Ochsner Journal
Arvind Chandrakantan, Tracie Saunders
Shared decision-making is a paradigm of patient engagement that is assuming greater importance in the era of value-based health care. The basic tenets include patient engagement on clinical decisions, taking into account multiple factors that influence physician and patient decision-making. Understanding and reconciling diametrically opposed views of care are important tenets of shared decision-making. Because many decisions are made preoperatively, the applicability of these principles may be useful especially in the situation of a higher risk surgical candidate...
March 2016: Anesthesiology Clinics
Shona Kalkman, Lotty Hooft, Johanne M Meijerman, Johannes T A Knape, Johannes J M van Delden
Automatic suspension of do-not-resuscitate (DNR) orders during general anesthesia does not sufficiently address a patient's right to self-determination and is a practice still observed among anesthesiologists today. To provide an evidence base for ethical management of DNR orders during anesthesia and surgery, the authors performed a systematic review of the literature to quantify the survival after perioperative cardiopulmonary resuscitation (CPR). Results show that the probability of surviving perioperative CPR ranged from 32...
March 2016: Anesthesiology
Jeffrey J Siracuse, Douglas W Jones, Ellen C Meltzer, Ashley R Graham, Gregory G Salzler, Peter H Connolly, Darren B Schneider, Andrew J Meltzer
BACKGROUND: Patients with Do Not Resuscitate (DNR) orders may still be offered surgery that aims to prolong or improve quality of life. The widely accepted approach of "required reconsideration" mandates that patients and surgeons discuss perioperative risks and expected outcomes in the context of the patient's values and preferences. However, surgical outcomes in this patient population have not been well-defined. The objectives of this study are to assess outcomes in DNR patients undergoing major vascular procedures, and develop an evidence basis for informed, shared decision-making...
October 2015: Annals of Vascular Surgery
Hassan Aziz, Bernardino C Branco, Jonathan Braun, John D Hughes, Kay R Goshima, Magdiel Trinidad-Hernandez, Glenn Hunter, Joseph L Mills
BACKGROUND: Do-not-resuscitate (DNR) orders allow patients to communicate their wishes regarding cardiopulmonary resuscitation. Although DNR status may influence physician decision making regarding resuscitation, the effect of DNR status on outcomes of patients undergoing emergency vascular operation remains unknown. The aim of this study was to analyze the effect of DNR status on the outcomes of emergency vascular surgery. METHODS: The National Surgical Quality Improvement Program database was queried to identify all patients requiring emergency vascular surgical interventions between 2005 and 2010...
June 2015: Journal of Vascular Surgery
Susan M Byrne, Svetlana Mulcahy, Myra Torres, Anita Catlin
Many of our elderly have now signed advance directives or physicians' order sets of life-sustaining treatment forms. Frequently, choices have been made for no life-sustaining interventions at the end of life or do-not-resuscitate (DNR) orders. As the proportion of elderly grows and more patients seek surgical intervention for comfort or to improve their quality of life, the medical and ethical issues of DNR orders in the perioperative setting become increasingly more complex. Many health care providers neither recognize the complexity and significance of the DNR order during the perioperative period nor have hospitals established actions toward resolution of this situation...
October 2014: Journal of Perianesthesia Nursing: Official Journal of the American Society of PeriAnesthesia Nurses
Bryan G Maxwell, Robert L Lobato, Molly B Cason, Jim K Wong
Background. Do-not-resuscitate (DNR) orders are often active in patients with multiple comorbidities and a short natural life expectancy, but limited information exists as to how often these patients undergo high-risk operations and of the perioperative outcomes in this population. Methods. Using comprehensive inpatient administrative data from the Public Discharge Data file (years 2005 through 2010) of the California Office of Statewide Health Planning and Development, which includes a dedicated variable recording DNR status, we identified cohorts of DNR patients who underwent major cardiac or thoracic operations and compared themto age- and procedure-matched comparison cohorts...
2014: PeerJ
Stephen P Williams, Christopher L Howe
Perhaps individual wishes are not always acknowledged or accepted when it comes to end-of-life care. This possibility, in conjunction with the experiences of healthcare risk managers, should cause concern in the healthcare risk management community. One particularly concerning issue where a persistent failure to honor a patient's wishes exists is with Do Not Resuscitate (DNR) orders in the perioperative arena. Despite a strong focus on informed consent and advance directives, evidence suggests a number of healthcare organizations either have no policy in place regarding DNR orders during the perioperative period, or, for those organizations that do have a policy, many call for automatic suspension of the DNR order without consultation with the patient...
2013: Journal of Healthcare Risk Management: the Journal of the American Society for Healthcare Risk Management
Christopher M Burkle, Keith M Swetz, Matthew H Armstrong, Mark T Keegan
UNLABELLED: HASH(0x330cfc0) BACKGROUND: In 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. METHODS: Five-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...
2013: BMC Anesthesiology
Thomas H Scott, Jonathan R Gavrin
Palliative care in the United States has made tremendous strides in the last decade. One of the most perplexing issues arises when a palliative care patient presents to the operating room with an already existing do-not-resuscitate (DNR) order. This article describes the most common conflicting issues that may arise and provides guidance to surgeons, anesthesiologists, patients, and their primary physicians to reach satisfactory resolution and optimal care. Anesthesia departments should appoint a liaison to surgical and perioperative nursing departments to provide education and create an atmosphere conducive to discussions with palliative care patients about goals of care, including DNR status...
March 2012: Anesthesiology Clinics
David B Waisel, Robert Simon, Robert D Truog, Hemanth Baboolal, Daniel B Raemer
INTRODUCTION: This study was performed to assess perioperative reevaluation of Do-Not-Resuscitate (DNR) orders by practicing anesthesiologists. METHODS: As part of an Anesthesia Crisis Resource Management course, an anesthesiologist interviewed a patient-actor with prostate cancer and bone metastases scheduled for a central venous catheter placement. The chart included a properly documented DNR order and the patient-actor's scripted responses emphasized that he would accept resuscitative efforts only "if the adverse clinical events were believed to be both temporary and reversible...
2009: Simulation in Healthcare: Journal of the Society for Simulation in Healthcare
Mark Ewanchuk, Peter G Brindley
Cardiopulmonary resuscitation (CPR) has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources. Despite the desire to respect patient autonomy, there are many reasons why withholding CPR may be complicated in the perioperative setting. This review outlines these factors in order to offer practical suggestions and to provoke discussion among perioperative care providers. Although originally described for witnessed intraoperative arrests, closed chest cardiac massage quickly became universal practice, and a legal imperative in many hospitals...
2006: Critical Care: the Official Journal of the Critical Care Forum
Matthew D Bacchetta, Soumitra R Eachempati, Joseph J Fins, Lynn Hydo, Philip S Barie
BACKGROUND: End-of-life decisions in the surgical ICU can be complicated by the unique characteristics of perioperative illness and the focus on life-extending interventions. We sought to determine whether illness severity correlated with the presence of DNR order in critically ill surgical patients. STUDY DESIGN: All surgical ICU patients who were given a DNR order from May 1, 1991 to May 31, 1998 were identified. Demographic data for all patients were collected prospectively...
June 2006: Journal of the American College of Surgeons
David B Waisel, Jeffrey P Burns, Judith A Johnson, George E Hardart, Robert D Truog
This paper reviews some of the difficulties in implementing perioperative reevaluation of do-not-resuscitate (DNR) orders and suggests several strategies for perioperative DNR policies. Policies should be written, designed and implemented at the level of the institution, and be sufficiently flexible to permit the tailoring of the perioperative DNR order to the individual patient. Policies should unambiguously state that reevaluation is required, delineate responsibilities for reevaluating the DNR order, state all the available options, define the necessary documentation, and list resources for help...
September 2002: Journal of Clinical Anesthesia
L Tungpalan, S Y Tan
Patients with do-not-resuscitate (DNR) orders may elect to have palliative surgery. Should DNR orders be automatically suspended in the operating room (OR)? This article addresses the following issues: (1) Ethics of DNR orders. (2) The American Society of Anesthesiology's Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders or Other Directives that Limit Treatment. (3) The Statement of the American College of Surgeons on Advance Directives by Patients. (4) Current hospital policies regarding perioperative DNR policies in Hawaii...
March 2001: Hawaii Medical Journal
V C Coopmans, C A Gries
Despite 2 decades of experience with do-not-resuscitate (DNR) orders, some controversy regarding their use still remains. By using a mailed questionnaire to a randomized sample of 500 active members of the American Association of Nurse Anesthetists, the present study explored the awareness, experiences, and opinions of nurse anesthetists regarding DNR orders for patients undergoing surgery. The purpose of the study was to evaluate the need for further education and discussion in this area. Of the 228 (45.6%) respondents, more than half had DNR policies at their facility, while the remainder reported no policy or were unsure whether a policy existed...
June 2000: AANA Journal
R Christopherson
No abstract text is available yet for this article.
1991: Perspectives in Healthcare Risk Management
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