By Naomi Goloff, MD, FAAP, University of Minnesota Masonic Children’s Hospital and Fairview Home Care and Hospice
The American Academy of Pediatrics (AAP) recently released new guidelines about intraoperative resuscitation for a patient with a serious illness and a pre-existing Do Not Attempt Resuscitation (DNAR) order.
Until recently, it had been standard practice to routinely “rescind” the DNAR in the perioperative period. Instead, the new AAP report describes a “required reconsideration” of the DNAR, a process of re-evaluation of DNAR orders that are incorporated into the process of informed consent prior to surgery and anesthesia.
It recommends an integrated approach involving attending anesthesiologists, surgeons, primary physicians or subspecialists and/or the palliative care team in these conversations. Essential components are clear documentation of the conversation and decisions, as well as clear communication with the entire team, especially the anesthesiologist and surgeon performing the case (many times the clinician getting consent, often with regards to anesthesia, will not be the one involved in the actual case). These recommendations also allow for a physician to withdraw from the case if he or she is unwilling or unable to implement the decision of the patient and/or family.
The report outlines 3 options or approaches for “required reconsideration.”
The first option is full resuscitation (ie a temporary suspension of DNAR order during the perioperative period). With this option, the team needs to determine the interval for suspension, and the DNAR order can be reinstated during the procedure by the surgeon or anesthesiologist in consultation with the family.
The second approach is a “goal directed approach” which focuses on the goals, values and preferences of the patient and family rather than individual procedures. This may be more vague or difficult to elucidate especially since many times the anesthesiologist and surgeon often don’t know patient and family well, and there is concern for decisions to be determined during time of an arrest.
The final option is the procedure-directed approach, with careful consideration of specific interventions that are more likely to be used in the specific surgery and the development of a perioperative resuscitation checklist (e.g. considerations with regards to airway management, blood products, invasive procedures such as chest tubes, defibrillation, resuscitative medications).
How can you help as the child’s pediatrician or pediatric subspecialist?
Resuscitation decisions are nuanced decisions that should be made in the context of patient and family values, goals and hopes, and reviewed in the context of the specific procedure. They can be agonizing decisions but are most often made out of the deepest love for the child, and deciding how to manage these decisions during a time of greater risk requires thoughtful consideration and not just an automatic response.
As a core member of the child’s medical team, whether you are the general pediatrician or the primary subspecialist, you often have a relationship with the child and family, an understanding of contextual factors, and can help guide the patient/family in the context of the disease course, the procedure, and in the context of their goals and values.
Medical care in 2018 means that we are often bringing more fragile children into the operating room for palliative procedures. These might ultimately extend a child’s life and/or contribute to its quality, but they also run the risk of resulting in deterioration intraoperatively (whether from intraoperative deterioration from surgery or anesthesia, versus progression or natural course of the child’s underlying disease).
True patient and family-centered care is a partnership, using our knowledge of their goals and values to help make these important decisions. And you, as their pediatrician, are well-positioned to help do this.
To read the AAP revised guideline report, go to https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Releases-Clinical-Report-on-Do-Not-Resuscitate-Orders.aspx