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Pediatric Perioperative DNR Orders: A Case Series in a Children's Hospital
Sydney E S Brown1, Ryan M Antiel2, Thane A Blinman3
1Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Insights
Systematic reconsideration of do-not-resuscitate (DNR) orders is often not documented in the perioperative period for pediatric patients. Opportunities exist to improve the management of DNR orders during this critical time.
Area of Science:
- Pediatric Palliative Care
- Perioperative Medicine
- Medical Ethics
Background:
- Do-not-resuscitate (DNR) orders are common in pediatric palliative care, yet children may still benefit from surgical procedures.
- Guidelines recommend systematic DNR order reconsideration during the perioperative period, but current practices are not well-documented.
Purpose of the Study:
- To evaluate the perioperative management of DNR orders in a tertiary care children's hospital.
- To identify gaps in the systematic reconsideration of DNR orders in the perioperative setting.
Main Methods:
- Retrospective review of electronic medical records for pediatric patients with DNR orders within 30 days of surgery.
- Data abstraction included patient/family wishes, DNR order status (continued, modified, suspended), and perioperative life-threatening events.
- Development of a process flow diagram for DNR order decision-making.
Main Results:
- 41% of procedures lacked documented systematic DNR order reconsideration.
- DNR orders were modified for 7% and suspended for 51% of procedures.
- Three pediatric patients (13%) experienced life-threatening events during the perioperative period.
Conclusions:
- Significant opportunities exist to enhance the management of DNR orders in the perioperative care of children.
- Standardized protocols and documentation are needed for DNR order reconsideration at key perioperative time points.
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 are limited.
Objectives:
To 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 February 1, 2016, to August 1, 2017. Using standardized case report forms, we abstracted the following from physician notes: 1) patient/family wishes with respect to the DNR, 2) whether preoperative DNR orders were continued, modified, or suspended during the perioperative period, and 3) 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 order 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 15 (51%). Three children (13%) suffered life-threatening events. We identified four time points in the perioperative period where systematic reconsideration should be documented in the medical record, and identified recommended personnel involved and important discussion points at each time point.
Conclusion:
Opportunities exist to improve how DNR orders are managed during the perioperative period.