AM Cyna

DJ Kutsogiannis

DK Heyland

L Bloomfield

M Ewanchuk

MS Eisenberg

MV Clemency

N Halpern

P Safar

Peter G Brindley

PG Brindley

PM Zoll

RD Truog

WB Kouwenhoven

BMC Anesthesiology

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Brindley BMC Anesthesiology 2013, 13:1http://www.biomedcentral.com/1471-2253/13/1COMMENTARY Open AccessPerioperative do-not-resuscitate orders: it is timeto talkPeter G BrindleyAbstractA study by Burkle et al. in BMC Anesthesiology examined attitudes around perioperative do-not-resuscitate orders.Questionnaires were given to patients, as well as to anesthesiologists, internists and surgeons. The study haslimitations and is open to interpretation. However, the findings are important. There appear to be attitudinaldifferences between patients and doctors, and between specialties. A small majority of patients are content to havea do-not-resuscitate order postponed during the perioperative period. A large majority expects opencommunication from doctors before proceeding. However, this article could also encourage a broader debate. Thisis about how to respect patient autonomy, while ensuring that resuscitation truly serves the patient’s best interests.This commentary outlines how more communication is needed at the bedside and in wider society.Keywords: Do not resuscitate, Perioperative, Cardiopulmonary resuscitationBackgroundCardiopulmonary resuscitation (CPR) can prevent prema-ture death. It can also prolong inevitable death, extendpatient suffering, consume scarce resources, and exacer-bate staff burnout [1-4]. As a result, CPR may representthe best and worst of acute care medicine. It is also cur-rently the only medical intervention expected for everyonewithout explicit contrary documentation. It is, therefore,an important topic for both practitioners and patients. Astudy by Burkle et al. [5] in BMC Anesthesiology addsto this discussion, but from an understudied area: theOperating Room (OR).Attitudes about perioperative do not resuscitate (DNR)ordersBurkle et al. [5] surveyed 500 patients and 384 doctorsregarding their attitudes to perioperative DNR orders.Limitations include the single centre and the reliance uponquestionnaires. Therefore, results may not be fully export-able to other jurisdictions, or to busy clinical practice. How-ever, the findings are useful and provocative. Firstly, whileover three-quarters of patients knew their resuscitationwishes, only approximately one-half had them recordedCorrespondence: peter.brindley@albertahealthservices.caDivision of Critical Care Medicine, University of Alberta, Edmonton, Alberta,Canada© 2013 Brindley; licensee BioMed Central Ltd.Commons Attribution License (http://creativecreproduction in any medium, provided the or(and one-quarter of those under 50-years). Presumably, thefirst lesson is to increase patient documentation.Burkle et al. found that 57% of patients believed that aperi-operative DNR should be suspended [5]. This con-trasted with only 18% of anesthesiologists, which in turncontrasts with 60% of anesthesiologists from a priorstudy [6]. The data suggests that attitudinal-gaps existbetween care-givers and care-receivers. Moreover, atti-tudes may have changed over time. Assumptions mayalso differ between medical specialties. This means thatthe issue of perioperative DNR has the potential for con-fusion and conflict. However, precisely because it is acomplex topic, it could also broaden our understandingof resuscitation within modern medical practice.It can be difficult to separate usual anesthesia from someform of resuscitation. Anesthesiologists routinely delivervasoactive agents, bolus fluids and intubate [7]. This makesit harder to distinguish between ordinary and extra-ordinary anesthetic care. It can also be difficult to separatethe intraoperative cardiac arrest that results from end-stage disease, as opposed to surgical or anesthetic iatroge-nesis [8]. Therefore, it has been argued that an “OR DNR”is different than a DNR elsewhere [7]. Similarly, an ORdeath is likely a different kind of death [6]. This may helpexplain why Burkle found that many clinicians were uncer-tain how to proceed [5]. This is an issue that needs to beThis is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly cited.Brindley BMC Anesthesiology 2013, 13:1 Page 2 of 3http://www.biomedcentral.com/1471-2253/13/1addressed, especially given that approximately 15% of sur-gical patients have some form of pre-existing DNR [7].How to proceed in the setting of a perioperativeDNR patientIn contrast, patients seem comparatively clear about howto proceed. For example, Burkle found that an overwhelm-ing majority (92%) expected to be spoken to prior to sur-gery [5]. It is worth stressing what this means. Meaningfulcommunication is more than just scripted words beforeanesthetic induction. Optimal communication requires acandid bilateral exchange, an examination of assumptions,and a confirmation of understanding [8]. This means thatpreoperative communication requires time, patience, andexperience. It also requires time to listen. This puts ad-ditional pressure on a busy OR.Communication breakdowns are not uncommon be-tween patients and clinicians. Regardless, if “communica-tion” means “sharing, uniting or making understandingcommon” [8] then both sides need to invest time andeffort. Fortunately, resources and strategies exist for theclinician [9]. Unfortunately, these non-technical skills arenot always taught, and are not usually innate [8,9]. It is nolonger enough for anesthesiologists to be only technically-proficient [9]. They should also be specialists in peri-operative communication [8]. Expressed another way,“verbal dexterity” should match procedural-dexterity andfactual-know-how [8]. Similarly, we should modernize ourunderstanding of resuscitation.DiscussionA more complete understanding of resuscitationSome practitioners, including Burkle et al., discuss resus-citation as an all-or-none proposition. In contrast, weshould separately address interventions such as chestcompressions, defibrillation and vasoactive agents [10].This takes more time but better reflects reality. After all,resuscitation of the pulseless patient is still very unlikely tobe successful despite decades of advances. In contrast, re-suscitating with a pulse is typically successful. In a typicalNorth American Intensive Care Unit (ICU), approximately80% of all-comers will survive to discharge. This compareswith only approximately 30% if CPR is required, and only10% if that CPR includes chest compressions [3].Over six decades, CPR has metamorphosed from “occa-sional” to “typical” to “expected” [2]. This is also worthdiscussing. All medical innovations are presumably con-ceived with noble intentions and intended only for selectpatients. However, the history of CPR shows how indica-tions expand, even when budgets do not. None of CPR’soriginators argued for it to be universal [11-13]. However,we now perform chest compressions on essentially anyonethat insists [2-4]. This means that autonomy is respected.It also means that compressions are no longer justified ina manner expected of treatments that are invasive, expen-sive, and typically unsuccessful. Despite consistent predic-tors of poor survival, we have nearly one million annualattempts in North America, and one billion dollars thatmight benefit patients elsewhere [1,2].The reality of cardiopulmonary resuscitationIn the developed world, approximately 70% of deathsnow occur in-hospital, and 25% of these in ICU [14,15].Therefore, death is increasingly an institutionalized andtechnologically-supported phenomenon [15]. UniversalCPR leads to universal ICU admission because post-arrest patients cannot be managed elsewhere. This helpsexplain why approximately 1% of U.S. GDP and 20-30%of the hospital budget is now spent on ICU [16,17]. Italso means that resuscitation discussions often occurunder pressure and between families and physicians whoare unfamiliar with each other [7].Burkle lauded that only 1/3rd as many anesthesiologistswould unilaterally suspend a DNR compared to a 1994 study[5,6]. Perhaps autonomy now supersedes all other consid-erations. However, there are other possibilities. Possibly,our definition of progress means that we do more butnever less. Perhaps it is the fear of litigation, or perhapsthat is an excuse to avoid lengthy or contentious discus-sions. Maybe it is simply easier to think in binary termsi.e. do everything or do nothing. Regardless, this authorworries that some doctors no longer feel authorized tostand by unpopular but considered opinions.ConclusionObviously resuscitation should be individualized, and ob-viously our ability to predict is imperfect. However, if wefail to communicate properly then we become mere tech-nicians who perform- but do not refuse- interventions,and who start- but do not stop- machines. We have failedto communicate that it is not technically difficult tomaintain some patients beyond any likelihood of leavinghospital. In addition, the majority of patients do not diebecause we cannot keep their heart and lungs going[14,15]. When we do stop it is not because of no otheroption, but rather because it is time. Physicians must ad-vocate, but not solely for more resources. We also needto advocate for time to talk, and to listen.Competing interestThe author declares that he has no competing interests.Authors’ contributionPB read and approved the final manuscript. PB drafted, revised andapproved the manuscript. All authors read and approved the finalmanuscript.Received: 28 November 2012 Accepted: 28 November 2012Published: 14 January 2013Brindley BMC Anesthesiology 2013, 13:1 Page 3 of 3http://www.biomedcentral.com/1471-2253/13/1References1. Eisenberg MS, Mengert TJ: Primary care: cardiac resuscitation. N Engl JMed 2001, 344(17):1304–12.2. Brindley PG, Markland DM, Mayers I, Kutsogiannis DJ: Predictors of survivalfollowing in-hospital adult cardiopulmonary resuscitation. Can Med AssocJ 2000, 167(4):343–8.3. Kutsogiannis DJ, Bagshaw SM, Laing B, Brindley PG: Predictors of SurvivalFollowing Adult Critical Care Cardiopulmonary Resuscitation. Can MAssoc J 2011, 183(14):1589–95.4. Brindley PG, Patel B, Farnan P: Psychological Burnout in Acute CareMedicine: “Physician Heal Thyself”. In Annual Update in Intensive Care andEmergency Medicine. Edited by Vincent JL. New York: Springer publishing;2012:811–819.5. Burkle G, et al: ms. doi:10.1186/1472-6939-13-31.6. Clemency MV, Thompson NJ: "Do not resuscitate" (DNR) orders in theperioperative period—a comparison of the perspectives ofanesthesiologists, internists, and surgeons. Anesth Analg 1994, 78(4):651–58.7. Ewanchuk M, Brindley PG: Perioperative do-not-resuscitate orders–doing'nothing' when 'something' can be done. Crit Care 2006, 10(4):219–223.8. Brindley PG, Reynolds SF: Improving verbal communication in critical caremedicine. J Crit Care 2011, 26:155–159.9. Cyna AM, Andrew MI, Tan SGM, Smith A: Handbook of Communication inAnaesthesia & Critical Care: A Practical Guide to Exploring the Art. Oxford, NewYork: Oxford University Press; 2011:2011. http://www.amazon.com/Handbook-Communication-Anaesthesia-Critical-Care/dp/0199577285.10. Alberta Health Services: Goals of Care Designations: Quick Reference Guide.http://www.albertahealthservices.ca/ps-1023351-103527-acp-goc-poster-11x17.pdf.11. Zoll PM, Linenthal AJ, Gibson W, Paul MH, Norman LR: Termination ofventricular fibrillation in man by externally applied electricalcountershock. N Engl J Med 1956, 254(16):727–32.12. Safar P: Mouth-to-mouth airway. Anesthesiology 1957, 18(6):904–6.13. Kouwenhoven WB, Jude JR, Knickerbocker GG: Closed-chest cardiacmassage. JAMA 1960, 173:1064–7.14. Truog RD, Brock DW, Cook DJ: Rationing in the intensive care unit.Crit Care Med 2006, 34:958–63.15. Heyland DK, Lavery JV, Tranmer J, et al: Dying in Canada: is it aninstitutionalized, technologically supported experience. J Palliat Care2000, 16:S10–16.16. Halpern N, Pastores S, Greenstein R, et al: Critical care medicine in theUnited States 1985–2000: an analysis of bed numbers, use, and costs.Crit Care Med 2004, 32:1254–59.17. Bloomfield L: The impact of economics on changing medical technologywith reference to critical care medicine in the United States.Anesth Analg 2003, 96:418–25.doi:10.1186/1471-2253-13-1Cite this article as: Brindley: Perioperative do-not-resuscitate orders: it istime to talk. BMC Anesthesiology 2013 13:1.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color ﬁgure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submit

Perioperative do-not-resuscitate orders: it is time to talk

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Perioperative do-not-resuscitate orders: it is time to talk

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