Palliative Care: Addressing End of Life Goals before the OR

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2 Palliative Care: Addressing End of Life Goals before the OR Valerie Schulz MD FRCPC MPH Founder, Palliative Medicine, Dept of Anesthesia & Perioperative Medicine, London Health Sciences Centre, Professor, University of Western Ontario, Associate Dean, Continuing Professional Development, Schulich School of Medicine & Dentistry, Western University

3 Disclosure No commercial financial COI Committee COI; Royal College: Founder, Palliative Medicine and Exam Committee for Palliative Medicine Research COI; Heart Failure and Palliative Care: MOTS, CIHR, AMOSO Career COI; Department of Anesthesia & Perioperative Medicine for Palliative Medicine; Associate Dean, CPD Schulich, Western

4 At the end of this session participants will be able to: 1. Recognize ethical issues regarding: 1. Do Not Resuscitate (DNR) in the Operating Room (OR) 2. Patient autonomy to request an applicable DNR, and 3. The physician s need to practice the Standard of Care 2. Identify components of the Required Reconsideration of DNR conversation prior to surgery 3. Consider Perioperative Supportive Care

5 Reflection Consider a patient you have encountered who requested limitations to resuscitation prior to surgery

6 Anesthesiology Societies Opinions Policies and practices that result in the automatic suspension or uncritical acceptance of DNR orders... are inappropriate. (CAS 2002) Canadian Anesthesiology Society (CAS) 2002, Committee on Ethics and Am Society of Anesthesiology 2013, American College of Surgeons, and Association of Operating Room Nurses (AORN) have similar statements

7 Advance Care Plan or DNR In appropriate cases, the availability of an Advance Care Plan (representation agreement, advanced directive, living will, do not resuscitate directive, etc.) should be ascertained, and its applicability to the proposed intervention should be determined and documented on the anesthetic assessment record. Guidelines to the Practice of Anesthesia, Revised Edition 2018, As recommended by the Canadian Anesthesiologists' Society

8 Mandatory Reconsideration of DNR It is necessary to have an automatic review of the code status for patients with a DNR status prior to surgery Smith KA, 2000 Know the ethics, law and policy for DNR in the OR in your practice location

9 Ethical Considerations The DNR Patient autonomy to request an applicable Do Not Resuscitate (DNR), Physician s need to practice the Standard of Care

10 DNR carries its own inherent risks, independent of the patients health state

11 Patient Autonomy Patients may request DNR in the OR Patients with DNR request surgery Indications for Palliative Cancer Surgery

12 Physicians provide the Standard of Care

13 Physician s Role Obtain consent Discussions cannot be delegated to other family members or physicians Respect for Persons In emergency situations

14 Goal of the Mandatory Reconsideration of DNR conversation Respect both The patient s wishes, interests, and values, and Provider clinical judgment, expertise, and ethical obligations for care If gap exists, attempt to clarify middle ground between patient wishes while maintaining standards of care

15 The Conversation Be caring Have a common understanding of an applicable DNR

16 Document the Conversation 1. Continue DNR as unchanged in the peri-operative period, if appropriate, and within the Standard of Care 2. Suspend DNR for an agreed-upon period 3. Limit resuscitation attempts within patient goals/wishes 4. Pt/SDM allow Anesthesiologist and Surgeon to use Clinical Judgment to provide Standard of Care in-keeping with the patients goals/wishes Wing Lok Chan, Palliative and Surgical Care (2015), 13, Sumrall W., et al, Ochsner Journal 16: , American Anesthesiologists Society

17 Place Recommendations into Context Consider the consequences of death in the OR

18 Dying and Death are social events

19 Consider Perioperative Medicine, integrated with Supportive Care / Palliative Care

20 Quality Improvement Opportunities Novel palliative surgical procedures and symptom management Novel anesthesia/analgesia practices for patient s at risk of dying, frail pts, uncontrolled cancer pain Research and define intra-operative practice standards for a patient at risk of dying Create health systems that support patient values/wishes

21 Should dual trained Anesthesiology / Palliative Medicine providers lead the integration of palliative care? Cobert J Copyright 2017 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.

22 Thanks for listening!

23 Reference Statement on Quality end-of-life care. American Anesthesiologists Society amended October, 2016 Bo Angela Wan, Collier Jiang, Arnav Agarwal et al. A review on the impact of do-notresuscitate orders on mortality and quality of care. J Pain Manage 2017;10(1):79-88 Canadian Anesthesiologists Society Committee on Ethics, 2002, Peri-Operative Status of Do Not Resuscitate (DNR)* Orders and Other Directives Regarding Treatment Cobert, J., Hauck, J., Flanagan, E., Knudsen, N., and Galanos, A.,.Anesthesia-Guided Palliative Care in the Perioperative Surgical Home Model. 2018,

24 References ETHICAL GUIDELINES FOR THE ANESTHESIA CARE OF PATIENTS WITH DO-NOT- RESUSCITATE ORDERS OR OTHER DIRECTIVES THAT LIMIT TREATMENT Committee of Origin: Ethics (Approved by the ASA House of Delegates on October 17, 2001, and last amended on October 16, 2013) GUIDELINES TO THE PRACTICE OF ANESTHESIA. Can J Anesth/J Can Anesth (2018) 65: DOI /s HAHO (Hospital Authority Head Office) Operations Circular No.9 (2014) HA guidelines on life-sustaining treatment in the terminally ill. Hong Kong: Hospital Authority. Available from Jones JW, McCullough LR, Defining, aligning, or declining do not resuscitate during surgery. Journal of Vascular Surgery (2014) 59, 4,

25 References Lassen C.L, et al. Perioperative Betreuung von Palliativpatienten durch den Anästhesisten Medizinische, psychosoziale und ethische Herausforderungen. Anaesthesist : Maxwell BG, Lobato RL, Cason MB, Wong JK. Perioperative morbidity and mortality of cardiothoracic surgery in patients with a do-not-resuscitation order (2014) PeerJ 2:e245; DOI /peerj.245 Miner T.J.. Communication as a Core Skill of Palliative Surgical Care. Anesthesiology Clin 30(2012) Sanderson A, Zurakowski D, Wolfe J. Clinicians Perspectives Regarding the Do-Not-Resuscitate Order. JAMA Pediatrics, 2013;167;10:954-8 Scarborough JE, Pappas TN. The Effect of Do-Not-Resuscitate Status on Postoperative Mortality in the Elderly Following Emergency Surgery. Advances in Surgery 17(2013);

26 References Scott & Gavrin. Palliative Surgery in the Do-Not-Resuscitate Patient: Ethics and Practical Suggestions for Management. Anesthesiology Clin 30(2012) 1-12 Smith KA, Do-Not-Resuscitate Orders in the Operating Room: Required Reconsideration. Military Medicine. 165,7:524,2000 Sumrall W., Mahanna E., Sabharwal V., Marshall T..Do Not Resuscitate, Anesthesia, and Perioperative Care: A Not So Clear Order. Ochsner Journal 16: , 2016 Sun, V., Krouse R..Palliative Surgery: Incidence and outcomes. Seminars in Oncology Nursing, Vol 30, No 4 (November), 2014: pp WAHL J., DYKEMAN MJ, WALTON T. HEALTH CARE CONSENT, ADVANCE CARE PLANNING, AND GOALS OF CARE PRACTICE TOOLS: THE CHALLENGE TO GET IT RIGHT. DECEMBER 2016, COMMISSIONED BY THE LAW COMMISSION OF ONTARIO, Advocacy Center for the Elderly (ACE), 0LCO.pdf Wing Lok Chan. The do-not-resuscitate order in palliative surgery: Ethical issues and a review on policy in Hong Kong. Palliative and Surgical Care (2015), 13,

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