Pediatric Perioperative DNR Orders: A Case Series in a Children's Hospital
Palliative Care; Do-Not-Resuscitate Orders; End of Life; Palliative Surgery; Perioperative Guideline Adherence
Context Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period is limited. Objectives Evaluate perioperative management of DNR orders at a tertiary care children�s hospital. Methods We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from 2/1/2016 � 8/1/2017. Using standardized case report forms, we abstracted the following from physician notes: (A) patient/family wishes with respect to the DNR, (B) whether pre-operative DNRs were continued, modified, or suspended during the perioperative period, and (C) whether life threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision making in the perioperative period. Results Twenty-three patients aged six days to 17 years had a DNR in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures, and suspended for fifteen (51%). Three children (13%) suffered life threatening events. We identified four time points where systematic reconsideration should be documented in the medical record, recommended personnel, and important discussion points at each time point. Conclusion Opportunities exist to improve how DNR orders are managed during the perioperative period.
Brown SES; Antiel RM; Blinman TA; Shaw S; Neuman Mark D; Feudtner C
Journal of Pain and Symptom Management
2019
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/j.jpainsymman.2019.01.006" target="_blank" rel="noreferrer noopener">10.1016/j.jpainsymman.2019.01.006</a>
Impact of a palliative care initiative on end-of-life care in the general wards: A before-and-after study._
Female; Humans; Male; retrospective studies; Palliative Care; Logistic Models; Aged; Comorbidity; cardiopulmonary resuscitation; Program Evaluation; Social Class; retrospective studies; DNAR; cardiopulmonary resuscitation; Resuscitation Orders; Chronic Disease/therapy; Palliative Care; DNAR Outcomes; Life Support Care/statistics & numerical data; Withholding Treatment/statistics & numerical data; Chronic Disease/epidemiology; Patient Admission/statistics & numerical data; Palliative Care; Hospital Mortality/trends; Advance Care Planning/st [Standards]; Forms and Records Control; Life Support Care/mt [Methods]; Advance Care Planning/standards; Asian; Chronic Disease/ep [Epidemiology]; Chronic Disease/th [Therapy]; Clinical Audit; Do-not-resuscitate orders; Forms and Records Control; general wards; Hospital Mortality/td [Trends]; Life Support Care/methods; Life Support Care/sn [Statistics & Numerical Data]; Patient Admission/statistics & numerical data; Patient Admission/td [Trends]; Patient Admission/trends; Resuscitation Orders; Singapore/ep [Epidemiology]; Singapore/epidemiology; Withholding Treatment/sn [Statistics & Numerical Data]
BACKGROUND: Data on deaths in the general wards of our hospital in 2007 revealed infrequent discussions on end-of-life care and excessive burdensome interventions., AIM: A physician order form to withhold inappropriate life-sustaining interventions was initiated in 2009. The use of the form was facilitated by staff educational sessions and a palliative care consult service. This study aims to evaluate the impact of these interventions in 2010., DESIGN: Retrospective medical chart review with comparisons was made for the following: baseline patient characteristics, orders concerning life-sustaining therapies, treatment provided in last 24 h of life, and discussion of specific life-sustaining therapies with patients and families., SETTINGS/PARTICIPANTS: This study included all adult patients who died in our hospital's general wards in 2007 (N = 683) versus 2010 (N = 714)., RESULTS: There was an increase in orders to withhold life-sustaining therapies, such as cardiopulmonary resuscitation (66.2%-80.0%). There was a decrease in burdensome interventions such as antibiotics (44.9%-24.9%) and a small increase in palliative treatments such as analgesia (29.1%-36.7%). There were more discussions on the role of cardiopulmonary resuscitation with conversant patients (4.6%-10.2%) and families (56.5%-79.8%) (p-value all < 0.05). On multivariate analysis, the physician order form independently predicted orders to withhold cardiopulmonary resuscitation., CONCLUSIONS: A multifaceted intervention of a physician order form, educational sessions, and palliative care consult service led to an improvement in documentation of end-of-life discussions and was associated with an increase in such discussions and less burdensome treatments. There were small improvements in the proportion of palliative treatments administered.
2014
Tan A; Seah A; Chua G; Lim Tow K; Phua J
Palliative Medicine
2014
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1177/0269216313484379" target="_blank" rel="noreferrer">10.1177/0269216313484379</a>
In What Circumstances Will A Neonatologist Decide A Patient Is Not A Resuscitation Candidate?
Futility; Intensive Care; Social Issues; Social Sciences; Biomedical; Ethics Medical; Slow Code; Uncertainty; Neonatologists; Practice; Decision Making; Analysis; Do-not-resuscitate Orders; Decision Making; Intensive Care; Pediatrics; Ethics; Pulmonary Arteries; Ostomy; Palliative Care; Medical Prognosis
End-of-life Care; Foetal Viability; Neonatology; Newborns And Minors; Palliative Care
Objective The purpose of this study was to determine the opinions of practising neonatologists regarding the ethical permissibility of unilateral Do Not Attempt Resuscitation (DNAR) decisions in the neonatal intensive care unit.
Study design An anonymous survey regarding the permissibility of unilateral DNAR orders for three clinical vignettes was sent to members of the American Academy of Pediatrics Section of Perinatal Medicine.
Results There were 490 out of a possible 3000 respondents (16%). A majority (76%) responded that a unilateral DNAR decision would be permissible in cases for which survival was felt to be impossible. A minority (25%) responded ‘yes’ when asked if a unilateral DNAR order would be permissible based solely on neurological prognosis.
Conclusions A majority of neonatologists believed unilateral DNAR decisions are ethically permissible if survival is felt to be impossible, but not permissible based solely on poor neurological prognosis. This has significant implications for clinical care.
Peter Daniel Murray; Denise Esserman; Mark Randolph Mercurio
Journal Of Medical Ethics
2016
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
doi:10.1136/medethics-2015-102941