Approach to the Do-Not-Resuscitate Patient in the Periendoscopic Period: Survey about the Current Portuguese Reality

Cardiopulmonary arrest is a rare but possible complication of endoscopic procedures, particularly when performed under sedation and/or analgesia. Hospitalized patients, and probably those with a Do-Not-Resuscitate (DNR) order, present a higher risk of severe cardiopulmonary complications during endoscopy. The request for endoscopic examination, particularly urgent procedures, is becoming increasingly more frequent in patients with DNR orders. In this study, we aimed to assess current practices, concepts, and guideline awareness of nationally surveyed Portuguese gastroenterologists regarding the approach to code status for DNR patients in the periendoscopic period.

Online anonymous and self-administered survey was adapted to the Portuguese reality and was conducted to assess gastroenterologists and gastroenterology trainees' basic demographics data and details about current practice, personal opinions, and knowledge of existing guidelines concerning the reversal of periprocedural DNR orders.

One hundred forty-five gastroenterologists, including 26 trainees (17.9%), responded to the survey. In patients with a DNR order, code status is rarely discussed (<25% of cases) with the patient/legal representative (66.9%, n = 97) or hospitalist (58.6%, n = 85), and the DNR order is also rarely reversed (reversal in all [100% of cases] or most cases [75-99% of cases] in 8.3%, n = 12). Most respondents were unaware of the procedures necessary for DNR prescription in Portugal (81.3%, n = 118), as well as existing guidelines on DNR reversal (96.5%, n = 140). Regarding personal beliefs, the majority considered that in these patients, the DNR order should be reversed to an intermediate option that includes limited resuscitation maneuvers (62.1%, n = 90) and that the urgency of a procedure should not influence the decision to reverse the DNR order (n = 89, 61.4%). There was consensus on the need for recommendations on this topic for gastroenterologists (97.9%, n = 142).

Portuguese gastroenterologists usually do not revisit the DNR order before endoscopic procedures as a matter of course and consequently do not reverse it. Furthermore, we found significant variation in practices and beliefs among Portuguese gastroenterologists in their approach to the patient with a DNR order, probably due to the unawareness and lack of specific existing guidelines.