In the Journals

AAP: Special considerations to be made for pediatric DNRs

A clinical report issued by the AAP Sections on Surgery, Anesthesia and Pain Medicine and the AAP Committee on Bioethics have highlighted the important considerations to be made regarding do not attempt resuscitation, also known as DNR or DNAR, orders in children and adolescents undergoing anesthesia and surgery.

“The AAP and the American Society of Anesthesiologists have issued guidelines on forgoing life-sustaining medical treatment, issues of informed consent and evaluation and preparation of pediatric patients undergoing anesthesia,” Mary E. Fallat, MD, FAAP, from the department of surgery at the University of Louisville, and colleagues wrote. “None of these policies offer a detailed approach for operative procedures considered for children with an existing DNAR order.”

The researchers noted that DNAR guidelines date back to the 1970s, with alternative names or abbreviations for the procedure varying geographically and not having a universal meaning.

To examine the various concerns that surround pediatric DNARs, including who is responsible for discussing the risks of cardiopulmonary arrest during anesthesia and surgery with caregivers, temporary suspension of DNARs during surgery and how long that suspension should last, the researchers wrote a clinical report regarding these considerations for children and adolescents.

Fallat and colleagues wrote that currently, DNARs are created by the treating physician, who will assess whether the child undergoing anesthesia or surgery would benefit from resuscitation efforts. This judgment may be made with or without consensus from the parents in certain circumstances, such as when the child has met state-level criteria for brain death. Additionally, the developmentally appropriate child and caregiver may come to an agreement in whether CPR should be administered during a cardiopulmonary arrest. A DNAR would be confirmed when the physician agrees.

The AAP Sections on Surgery, Anesthesia and Pain Medicine and the AAP Committee on Bioethics have recorded the special considerations that should be made regarding a child's do not attempt resuscitation orders when they are to undergo anesthesia and surgery.
Source: Shutterstock.com

According to the researchers, when caregivers, children and physicians agree on a DNAR, it is assumed that a cardiopulmonary arrest would be an unexpected event related to the dying process of the child who experiences a life-threatening illness. These children would have anticipated failure in bodily function over time; however, many surgeons and anesthesiologists have special considerations to make because anesthesia may induce some degree of hemodynamic abnormality that could spur cardiopulmonary arrest.

Furthermore, many of the routine manipulations made by anesthesiologists may be considered resuscitative. These manipulations are used only in the perioperative period to re-establish spontaneous respiration and circulation following a cardiopulmonary arrest. Fallat and colleagues write that surveys administered to physicians and patients that have an established DNAR report that clarification regarding these measures is needed when interpreting DNARs.

When a physician approaches the topic of writing a DNAR for a child, they often believe that beginning the process of resuscitation would prolong the dying process and not benefit the patient. The surgeons and anesthesiologists are not commonly involved in decision-making processes regarding DNARs and, therefore, cannot guarantee that the implications of this decision were discussed in the context of the perioperative setting. Fallat and colleagues recommend that an evaluation of a child’s DNAR be conducted before an operation, which would include input from caregivers, the surgeon and the anesthesiologist.

“There is often no previous relationship established between the patient, parents and surgical team, with the exception of a brief preoperative assessment,” Fallat and colleagues wrote. “Active listening and compassionate understanding are essential and are a critical part of patient- and family-centered care. Using an integrated approach by including the hospitalist, intensive care or palliative care team in the discussion is appropriate and may be more comfortable for the family.”

Sometimes, a physician may not agree with caregivers’ wishes regarding their child’s DNAR. If this is the case, parental choice overrides physician opinion. It may be appropriate for a physician to professionally refuse to participate in the child’s care when parental beliefs do not align with the physician’s medical, ethical or moral views. A physician may then withdraw from a case once continuity of care has been established. Additional counseling from an institutional ethics committee may be warranted.

When a DNAR is written, two approaches may be taken, including procedure- and goal-directed orders. The researchers wrote that patients and parents are commonly less concerned about the approaches used for resuscitation and mare more worried about subjective and personal concerns related to quality of life before and after resuscitation is administered.

“An approach that honors the family’s treatment goals while reflecting the reality and unique aspects of the perioperative environment is promulgated with this model,” Fallat and colleagues wrote. “However, some anesthesiologists are uncomfortable with the indeterminate nature of a goal-directed DNAR order and have ethical or legal concerns about having such crucial decisions rest solely on their best judgment at the time of an arrest.”

The researchers suggest the following elements be included when reconsidering a DNAR or limited resuscitation orders for a child:

  • Discussing with caregivers and the developmentally-appropriate child or teenager the risk of the child needing resuscitative efforts, causes of arrest and whether they can be reversed, rate of success and possible outcomes when resuscitation is provided or not provided;
  • Approving which resuscitative measures should be used if resuscitation is agreed upon;
  • Deciding whether to maintain or suspend a DNAR in light of an upcoming procedure, what benefits they will receive from resuscitation and the level of patient compromise related to the procedure;
  • Recording features of this discussion in the patient’s medical record;
  • Collaborating with surgeons to honor DNAR orders with relevant staff;
  • Identifying another health care professional who can replace the physician or health care profession in the event they must withdraw from the case;
  • Understanding that caregiver or patient requests to refuse resuscitation during the procedure can be compatible with using therapeutic measures, excluding chest compressions and defibrillation, for conditions other than cardiopulmonary arrest; and
  • Preparing to discuss withdrawing life support after a set amount of time if the family withdraws the DNAR order in the operating room and resuscitation efforts were used successfully, but the process of dying has been prolonged as a result of resuscitative efforts. – by Katherine Bortz

Disclosures: The authors report no relevant financial disclosures.

A clinical report issued by the AAP Sections on Surgery, Anesthesia and Pain Medicine and the AAP Committee on Bioethics have highlighted the important considerations to be made regarding do not attempt resuscitation, also known as DNR or DNAR, orders in children and adolescents undergoing anesthesia and surgery.

“The AAP and the American Society of Anesthesiologists have issued guidelines on forgoing life-sustaining medical treatment, issues of informed consent and evaluation and preparation of pediatric patients undergoing anesthesia,” Mary E. Fallat, MD, FAAP, from the department of surgery at the University of Louisville, and colleagues wrote. “None of these policies offer a detailed approach for operative procedures considered for children with an existing DNAR order.”

The researchers noted that DNAR guidelines date back to the 1970s, with alternative names or abbreviations for the procedure varying geographically and not having a universal meaning.

To examine the various concerns that surround pediatric DNARs, including who is responsible for discussing the risks of cardiopulmonary arrest during anesthesia and surgery with caregivers, temporary suspension of DNARs during surgery and how long that suspension should last, the researchers wrote a clinical report regarding these considerations for children and adolescents.

Fallat and colleagues wrote that currently, DNARs are created by the treating physician, who will assess whether the child undergoing anesthesia or surgery would benefit from resuscitation efforts. This judgment may be made with or without consensus from the parents in certain circumstances, such as when the child has met state-level criteria for brain death. Additionally, the developmentally appropriate child and caregiver may come to an agreement in whether CPR should be administered during a cardiopulmonary arrest. A DNAR would be confirmed when the physician agrees.

The AAP Sections on Surgery, Anesthesia and Pain Medicine and the AAP Committee on Bioethics have recorded the special considerations that should be made regarding a child's do not attempt resuscitation orders when they are to undergo anesthesia and surgery.
Source: Shutterstock.com

According to the researchers, when caregivers, children and physicians agree on a DNAR, it is assumed that a cardiopulmonary arrest would be an unexpected event related to the dying process of the child who experiences a life-threatening illness. These children would have anticipated failure in bodily function over time; however, many surgeons and anesthesiologists have special considerations to make because anesthesia may induce some degree of hemodynamic abnormality that could spur cardiopulmonary arrest.

Furthermore, many of the routine manipulations made by anesthesiologists may be considered resuscitative. These manipulations are used only in the perioperative period to re-establish spontaneous respiration and circulation following a cardiopulmonary arrest. Fallat and colleagues write that surveys administered to physicians and patients that have an established DNAR report that clarification regarding these measures is needed when interpreting DNARs.

When a physician approaches the topic of writing a DNAR for a child, they often believe that beginning the process of resuscitation would prolong the dying process and not benefit the patient. The surgeons and anesthesiologists are not commonly involved in decision-making processes regarding DNARs and, therefore, cannot guarantee that the implications of this decision were discussed in the context of the perioperative setting. Fallat and colleagues recommend that an evaluation of a child’s DNAR be conducted before an operation, which would include input from caregivers, the surgeon and the anesthesiologist.

“There is often no previous relationship established between the patient, parents and surgical team, with the exception of a brief preoperative assessment,” Fallat and colleagues wrote. “Active listening and compassionate understanding are essential and are a critical part of patient- and family-centered care. Using an integrated approach by including the hospitalist, intensive care or palliative care team in the discussion is appropriate and may be more comfortable for the family.”

Sometimes, a physician may not agree with caregivers’ wishes regarding their child’s DNAR. If this is the case, parental choice overrides physician opinion. It may be appropriate for a physician to professionally refuse to participate in the child’s care when parental beliefs do not align with the physician’s medical, ethical or moral views. A physician may then withdraw from a case once continuity of care has been established. Additional counseling from an institutional ethics committee may be warranted.

When a DNAR is written, two approaches may be taken, including procedure- and goal-directed orders. The researchers wrote that patients and parents are commonly less concerned about the approaches used for resuscitation and mare more worried about subjective and personal concerns related to quality of life before and after resuscitation is administered.

“An approach that honors the family’s treatment goals while reflecting the reality and unique aspects of the perioperative environment is promulgated with this model,” Fallat and colleagues wrote. “However, some anesthesiologists are uncomfortable with the indeterminate nature of a goal-directed DNAR order and have ethical or legal concerns about having such crucial decisions rest solely on their best judgment at the time of an arrest.”

The researchers suggest the following elements be included when reconsidering a DNAR or limited resuscitation orders for a child:

  • Discussing with caregivers and the developmentally-appropriate child or teenager the risk of the child needing resuscitative efforts, causes of arrest and whether they can be reversed, rate of success and possible outcomes when resuscitation is provided or not provided;
  • Approving which resuscitative measures should be used if resuscitation is agreed upon;
  • Deciding whether to maintain or suspend a DNAR in light of an upcoming procedure, what benefits they will receive from resuscitation and the level of patient compromise related to the procedure;
  • Recording features of this discussion in the patient’s medical record;
  • Collaborating with surgeons to honor DNAR orders with relevant staff;
  • Identifying another health care professional who can replace the physician or health care profession in the event they must withdraw from the case;
  • Understanding that caregiver or patient requests to refuse resuscitation during the procedure can be compatible with using therapeutic measures, excluding chest compressions and defibrillation, for conditions other than cardiopulmonary arrest; and
  • Preparing to discuss withdrawing life support after a set amount of time if the family withdraws the DNAR order in the operating room and resuscitation efforts were used successfully, but the process of dying has been prolonged as a result of resuscitative efforts. – by Katherine Bortz

Disclosures: The authors report no relevant financial disclosures.