Advertisement

Do-not-resuscitate orders and high-risk pediatric surgery: professional nuisance or medical necessity?

      Abstract

      Background

      There is a paucity of data in the literature regarding end-of-life care and do-not-resuscitate (DNR) status of the pediatric surgical patient, although invasive procedures are frequently performed in very high risk and critically ill children. Despite significant efforts in adult medicine to enhance discussions around end-of-life care, little is known about similar endeavors in the pediatric population.

      Methods

      A retrospective review of the National Surgical Quality Improvement Program Pediatric database was performed. Patients aged <18 y with American Society of Anesthesiologists class 3 or greater who underwent elective surgical procedure in 2012-2013 were included. Demographic factors, principal diagnosis, associated conditions, DNR status, and mortality were extracted. Descriptive analysis was performed.

      Results

      A total of 20,164 patients met the inclusion criteria. Only 36 (0.2%) patients had a signed DNR order before surgical procedure. Of severely ill American Society of Anesthesiologists four patients, only 1% had DNR status. There were no differences in gender, race, ethnicity, or surgical specialty by the presence of a DNR order. Notably, 17.1% of children who died within this period had multiple surgical procedures performed before expiring.

      Conclusions

      The rate of documented DNR status is extremely low in the high-risk pediatric surgical population undergoing elective surgery, even among severely ill children. Well-informed end-of-life care discussions in a patient-focused approach are essential in the surgical care of children with complex medical conditions and critical illness. Better documentation of DNR discussion will also allow better tracking and benchmarking.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Surgical Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Brock K.E.
        • Steineck A.
        • Twist C.J.
        Trends in end-of-life care in pediatric hematology, oncology, and stem cell transplant patients.
        Pediatr Blood Cancer. 2016; 63: 516-522
        • Dingfield L.
        • Bender L.
        • Harris P.
        • et al.
        Comparison of pediatric and adult hospice patients using electronic medical record data from nine hospices in the United States, 2008-2012.
        J Palliat Med. 2015; 18: 120-126
        • La Puma J.
        • Silverstein M.D.
        • Stocking C.B.
        • Roland D.
        • Siegler M.
        Life-sustaining treatment. A prospective study of patients with DNR orders in a teaching hospital.
        Arch Intern Med. 1988; 148: 2193-2198
        • Kazaure H.
        High mortality in surgical patients with do-not-resuscitate orders.
        Arch Surg. 2011; 146: 922-928
        • Fallat M.E.
        • Deshpande J.K.
        • American Academy of Pediatrics Section on Surgery, Section on Anesthesia and Pain Medicine, and Committee on Bioethics
        Do-not-resuscitate orders for pediatric patients who require anesthesia and surgery.
        Pediatrics. 2004; 114: 1686-1692
        • Santos K.G.
        • Fallat M.E.
        Surgical and anesthetic decisions for children with terminal illness.
        Semin Pediatr Surg. 2001; 10: 237-242
        • Garros D.
        • Rosychuk R.J.
        • Cox P.N.
        Circumstances surrounding end of life in a pediatric intensive care unit.
        Pediatrics. 2003; 112: e371
        • Solomon M.Z.
        • Sellers D.E.
        • Heller K.S.
        • et al.
        New and lingering controversies in pediatric end-of-life care.
        Pediatrics. 2005; 116: 872-883
        • Hammes B.J.
        • Klevan J.
        • Kempf M.
        • Williams M.S.
        Pediatric advance care planning.
        J Palliat Med. 2005; 8: 766-773
        • Bateman L.B.
        • Tofil N.M.
        • White M.L.
        • Dure L.S.
        • Clair J.M.
        • Needham B.L.
        Physician communication in pediatric end-of-life care: a simulation study.
        Am J Hosp Palliat Med. 2016; 33: 935-941
        • Sanderson A.
        • Hall A.M.
        • Wolfe J.
        Advance care discussions: pediatric clinician preparedness and practices.
        J Pain Symptom Manage. 2016; 51: 520-528
        • Wocial L.
        • Ackerman V.
        • Leland B.
        • et al.
        Pediatric ethics and communication excellence (PEACE) rounds: decreasing moral distress and patient length of stay in the PICU.
        HEC Forum. 2017; 29: 75-91