A new clinical report from the American Academy of Pediatrics (AAP) says that existing Do-Not-Resuscitate Orders (DNR) for children should be reevaluated when the child requires surgery.
A DNR order prohibits resuscitative efforts from being undertaken in the event of a cardiac arrest. According to the report, "Do-Not-Resuscitate Orders for Pediatric Patients Who Require Anesthesia and Surgery," a pediatric patient's DNR order should be reevaluated before an operative procedure because surgery and anesthesia introduce additional risks to the patient.
When a parent or surrogate consents to a DNR order, it is under the assumption that cardiac arrest will be a direct consequence of the child's underlying disease. Because surgeons and anesthesiologists are rarely involved in the original DNR decision, it is unlikely that implications of the DNR status in the operating room were discussed with the patient's parent or surrogate. Therefore, the parent or surrogate, the surgeon and the anesthesiologists should reevaluate the DNR order for a child who requires an operation. This reevaluation process is called "required reconsideration" and should be incorporated into the process of informed consent for surgery and anesthesia.
The report advises hospitals wishing to develop a "required reconsideration" policy to address the following elements:
Include in the discussion with a child's parent or surrogate information about the likelihood of requiring resuscitative measures, a description of these measures and their reversibility, the chance of success, and possible outcomes with and without resuscitation.
Make the decision to uphold or suspend a DNR order on the basis of the planned procedure, the anticipated benefit for the child, and the likelihood of patient compromise as a result of the procedure.
Document the main features of the physician-family discussions in the medical record.
Communicate plans to honor an intraoperative (during the course of surgery) DNR order among relevant staff.
Require any physician or other health care professional who is unwilling to honor a family's refusal of resuscitation to withdraw from the case, and identify alternate health care professionals willing to honor the DNR in the operating room.
The report also recommends that hospital staff make a provision to discuss withdrawal of life support after a determined amount of time, if the patient's process of dying has been prolonged as a result of resuscitation during an operation.