Guideline:
Do-not-resuscitate orders for pediatric patients who require anesthesia and surgery
Bibliographic Source(s)
- Fallat ME Deshpande JK. Do-not-resuscitate orders for pediatric patients who require anesthesia and surgery. Pediatrics 2004 Dec;114(6):1686-92. [31 references] PubMed
Guideline Status
This is the current release of the guideline.
American Academy of Pediatrics (AAP) Policies are reviewed every 3 years by the authoring body at which time a recommendation is made that the policy be retired revised or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation or retires a statement the current policy remains in effect.
Guideline Category
Management
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Hospitals
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
To provide recommendations for the use of do-not-resuscitate orders for pediatric patients who require anesthesia and surgery
Target Population
Pediatric patients with preexisting do-not-resuscitate orders who require anesthesia and surgery
Interventions and Practices Considered
- Informed consent
- "Required reconsideration" of do-not-resuscitate (DNR) orders
- Patient/parent education/discussion
- Documentation in medical record
- Patient/parent wishes
- Interval of DNR suspension if appropriate
- Communicate DNR orders to relevant staff and identify staff who are willing to honor the DNR request
- Referral to ethics committee as appropriate
Major Outcomes Considered
Not stated
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Searches were done using PubMed and specialty society surveys.
Number of Source Documents
Two surveys
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Subjective Review
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Not stated
Major Recommendations
Informed Consent
To respect the child's and family's wishes physicians must obtain informed permission from a parent or surrogate before a child can undergo any medical intervention including surgery and resuscitation. Ordinarily resuscitation efforts do not require informed consent because they are deemed emergency interventions and consent is implied. However terminally ill or severely disabled children and their parents are often confronted with the decision of whether resuscitation should be attempted in the event the child's underlying disease results in cardiopulmonary arrest.
Customarily physicians will approach the parent or surrogate about instituting a do-not-resuscitate (DNR) order when it is felt that resuscitation of the child would not be beneficial and would only prolong the time to death. When a parent or surrogate consents to a DNR order it is under the assumption that cardiopulmonary arrest will be a direct consequence of the child's underlying disease. Surgery and anesthesia constitute a change in the child's medical status because they introduce additional risks to the patient. Because surgeons and anesthesiologists are rarely involved in the original DNR decision they cannot be certain that the implications of the DNR status in the perioperative setting were discussed with the patient's parent (or other surrogate). Therefore the parent or surrogate the surgeon and the anesthesiologist should reevaluate the DNR order for a child who requires an operative procedure. This reevaluation process has been called "required reconsideration" and should be incorporated into the process of informed consent for surgery and anesthesia. Discussions regarding consent under these circumstances should be initiated by attending staff particularly in hospitals with residency teaching programs in which residents may be routinely involved in the consent process.
The surgeon and anesthesiologist must approach the parents and child with compassion. There is often no previous relationship established between the patient parents and surgical team precluding a brief preoperative assessment. "Active listening" is essential. The parent or surrogate should be asked about specific interventions and their understanding of the relative merits of each of these interventions during resuscitation (see Table 3 in the original guideline document).
Airway management should be determined by what is mandated by the child's condition and the surgical procedure. Specific prohibition of tracheal intubation is problematic and beliefs and concerns must be carefully elicited and discussed. Exceptions to the injunctions against intervention should be specifically noted in the patient's medical record. The parent may agree to a temporary suspension of the DNR order during the perioperative period. If so the temporal end point to the DNR suspension needs to be recorded as well. If an agreement cannot be obtained after thorough discussion the wishes of the informed parent or surrogate must prevail. In some cases the parents may feel that the burden of a therapy is not worth the potential benefits and decline the procedure. When an individual physician feels that the parent's wishes are inconsistent with his or her medical ethical or moral views the physician should withdraw from the case after ensuring continuity of care (American Academy of Pediatrics [AAP] 1994) and could consider consulting the institutional ethics committee.
Role of the Surgeon
The following are operative interventions that might be considered for a pediatric patient with a DNR order:
- Provision of a support device that will enable the child to be discharged from the hospital (e.g. gastrostomy tube or tracheostomy).
- Urgent surgery for a condition unrelated to the underlying chronic problem (e.g. acute appendicitis in a terminal cancer patient)
- Urgent surgery for a condition related to the underlying chronic problem but not believed to be a terminal event (e.g. a pathologic fracture or bowel obstruction).
- A procedure to decrease pain
- A procedure to provide vascular access.
It is the duty of the operating surgeon to discuss risks of a procedure with the parent or other surrogate of any pediatric patient including how the patient's condition might influence the risk of anesthesia.
It is expected that the surgeon will advise parents or other surrogates and the child (if developmentally appropriate) regarding operative risks and benefits and advocate a policy of required reconsideration of previous DNR orders. The results of all discussions should be documented in the patient's medical record. The surgeon should also ultimately convey the patient's wishes to the members of the entire operating room team help operating team members understand the patient's or surrogate's wishes and find alternate team members to replace individuals who disagree with the patient's or surrogate's wishes. With children the difficulty arises when there is no one who is willing to honor a family's wish to continue the DNR status during the anesthesia and surgery. Stalemates such as this should be referred to the ethics committee of the institution.
Role of the Anesthesiologist
Anesthesiologists have the duty to inform the parent or other surrogate of the risks and potential benefits of intraoperative resuscitation. Required reconsideration as part of the process of informed consent for anesthesia eliminates ambiguities and misunderstandings associated with patients who have DNR orders by providing anesthesiologists with the opportunity to educate the parent (or other surrogate) to become familiar with their values and perceptions of the child's quality of life and together clarify how the child's DNR order should be interpreted perioperatively. By giving parents or surrogates and clinicians the option of deciding from among full resuscitation limitations based on procedures or limitations based on goals the child's needs are individualized and better served. Regardless of the decision made by the parent or other surrogate the individual acting on behalf of the child must be readily available for consultation during the procedure.
If DNR Orders are Suspended: Qualification of Perioperative Interval
If the family or medical personnel involved in a child's care choose to suspend DNR orders during anesthesia and surgery it is necessary to define the duration of suspension (Clemency & Thompson 1997). The physiologic effects of anesthesia and surgery rarely terminate at the end of the procedure but the duration thereafter depends on the anesthetic technique used and the type of surgical procedure performed. The acute effects of most anesthetic medications generally resolve within several hours or 1 day after surgery and most anesthesiologists visit the patient the day after a surgical procedure and document recovery status in the patient record. Recovery of respiratory function after surgery depends on preoperative pulmonary function chronicity of illness and length of the procedure. Some patients will experience cardiopulmonary arrest during or immediately after surgery which may be the result of an acute and reversible complication. It is appropriate to use mechanical ventilation after surgery as long as the patient continues to show significant and sustained improvement in pulmonary function. Once the patient ceases to recover or deteriorates withdrawal of ventilatory support should be considered. Generally speaking the suspension of DNR orders should continue until the postanesthetic visit until the patient has been weaned from mechanical ventilation or until the primary physician involved in the patient's care and the family agree to reinstate the DNR order.
The surgeon and anesthesiologist should feel comfortable and should be allowed to reinstate a DNR order intraoperatively through consultation with the family under certain conditions. For example if cardiac arrest occurs during surgery and it is apparent that the arrest is the result of an irreversible underlying disease or complication and that cardiopulmonary resuscitation (CPR) would only allow continued deterioration the DNR order should be reinstated. If resuscitation measures are withheld and intraoperative arrest occurs such a death should be classified as "expected" for quality assurance purposes rather than "unexpected." Expected deaths do not require mandatory quality assurance review (Igoe Cascella & Stockdale 1993; Youngner Cascorbi & Shuck 1991)
Clinical Algorithm(s)
None provided
References Supporting the Recommendations
- American Academy of Pediatrics Committee on Bioethics: Guidelines on foregoing life-sustaining medical treatment. Pediatrics 1994 Mar;93(3):532-6. PubMed
- Clemency MV Thompson NJ. Do not resuscitate orders in the perioperative period: patient perspectives. Anesth Analg 1997 Apr;84(4):859-64. PubMed
- Igoe S Cascella S Stockdale K. Ethics in the OR: DNR and patient autonomy. Nurs Manage 1993 Sep;24(9):112A 112D 112H. PubMed
- Youngner SJ Cascorbi HF Shuck JM. DNR in the operating room. Not really a paradox. JAMA 1991 Nov 6;266(17):2433-4. PubMed
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
- This guideline is intended to help clinicians appropriately manage pediatric patients with preexisting do-not-resuscitate orders who require anesthesia and surgery.
- By giving parents or other surrogates and clinicians the option of deciding from among full resuscitation limitations based on procedures or limitations based on goals the child's needs are individualized and better served.
Potential Harms
Not stated
Qualifying Statements
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations taking into account individual circumstances may be appropriate.
Description of Implementation Strategy
Implementing "Required Reconsideration"
Hospitals are encouraged to develop and maintain written policies permitting the forgoing of life-sustaining treatment of patients including children in appropriate circumstances. Once a DNR order is in place according to accepted standards it is important that it be reviewed before surgery to determine applicability in the operating room and the postoperative recovery period. Hospitals wishing to develop a "required reconsideration" policy may want to address the following elements:
- Include in the discussion with a child's parent or other surrogate information about the likelihood of requiring resuscitative measures a description of these measures and their reversibility the chance of success and possible outcomes with and without resuscitation. Establish an agreement about what if any resuscitative measures will be instituted during the procedure.
- Make the decision to uphold or suspend a DNR order on the basis of the planned procedure the anticipated benefit for the child and the likelihood of patient compromise as a result of the procedure.
- Document the salient features of the physician-family discussion in the medical record.
- Communicate plans to honor an intraoperative DNR order among relevant staff.
- Require any physician or other health care professional who is unwilling to honor a family's refusal of resuscitation to withdraw from the case and allow others to assume care. The withdrawing physician or health care professional should make a conscientious effort to identify another physician who is willing to honor the DNR request. (American Academy of Pediatrics Committee on Bioethics 1994)
- Recognize that a patient's or surrogate's decision to refuse intraoperative resuscitation can be compatible with the provision of therapeutic measures to treat conditions other than arrest. This decision does not necessarily imply limits on other forms of care such as intensive care.
- If the family chooses to rescind the DNR order in the operating room and arrest occurs with resuscitation but the patient's process of dying has only been prolonged make a provision to discuss withdrawal of life support after a determined amount of time.
IOM Care Need
End of Life Care
Getting Better
Living with Illness
IOM Domain
Patient-centeredness
Bibliographic Source(s)
- Fallat ME Deshpande JK. Do-not-resuscitate orders for pediatric patients who require anesthesia and surgery. Pediatrics 2004 Dec;114(6):1686-92. [31 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Academy of Pediatrics
Guideline Committee
Section on Surgery
Section on Anesthesia and Pain Medicine
Committee on Bioethics
Composition of Group that Authored the Guideline
Section on Surgery 2004-2005: Donna A. Caniano MD Chairperson; Richard R. Ricketts MD; Brad W. Warner MD;
Kurt D. Newman MD; Michael D. Klein MD; Ann M. Kosloske MD Past Section Chairperson; Richard Andrassy MD Past Section Chairperson; Richard Azizkhan MD Past Section Chairperson; Thomas R. Weber MD Past Section Chairperson
Consultants: Jane Goldsmith PhD; Katia G. Santos MD
Staff: Chelsea Kirk
Section on Anesthesiology and Pain Medicine 2004-2005: Thomas Mancuso MD Chairperson; Joseph Cravero MD; Constance Houck MD; Zeev Kain MD; Lynne Maxwell MD; Robert Valley MD; Rita Agarwal MD; Lynne Ferrari MD Past Section Chairperson; Patty Davidson MD Past Section Executive Committee Member; Jayant K. Deshpande MD Past Section Executive Committee Member
Staff: Kathleen Kuk Ozmeral
Committee on Bioethics 2004-2005: Jeffrey R. Botkin MD MPH; Douglas S. Diekema MD MPH; Mary E. Fallat MD; Eric D. Kodish MD; Steven R. Leuthner MD; Lainie Friedman Ross MD PhD; G. Kevin Donovan MD MLA; John T. Truman MD MPH Past Committee Member; Benjamin S. Wilfond MD Past Committee Member
Liaisons: Christine E. Harrison MD Canadian Paediatric Society; Neil W. Boris MD American Academy of Child and Adolescent Psychiatry; Marcia Levetown MD American Board of Pediatrics; Arlene J. Morales MD American College of Obstetricians and Gynecologists; Alessandra (Sandi) Kazura MD Past Committee Liaison; Ernest F. Krug III MDiv MD Past Committee Liaison; Michael K. Lindsay MD Past Committee Liaison
Consultant: Dena S. Davis JD PhD
Staff: Alison Baker MS
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
American Academy of Pediatrics (AAP) Policies are reviewed every 3 years by the authoring body at which time a recommendation is made that the policy be retired revised or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation or retires a statement the current policy remains in effect.
Guideline Availability
Electronic copies: Available from the American Academy of Pediatrics (AAP) Policy Web site.
Print copies: Available from American Academy of Pediatrics 141 Northwest Point Blvd. P.O. Box 927 Elk Grove Village IL 60009-0927.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on February 4 2005. The information was verified by the guideline developer on March 15 2005.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor American Academy of Pediatrics (AAP) 141 Northwest Point Blvd Elk Grove Village IL 60007.
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