ASA guidelines for perioperative management of do-not-resuscitate (DNR) orders recommend that we revisit existing DNR orders prior to surgery and modify them as needed to align with patient preferences and clinical circumstances (asamonitor.pub/3lq2jgi). This “revisit and revise” or “required reconsideration” approach is a clear step beyond “automatic reversal” of DNR orders in that it preserves patients’ rights to self-determination and promotes patient-centered decision-making (Anesthesiology 1991;74:606-8). These guidelines are silent, however, regarding the vast majority of patients who present for surgery without DNR orders in place, and it is generally assumed that such patients desire to be “full code.” The aging of the United States population, a heightened understanding of age-related vulnerabilities, and a growing focus on goal-concordant care suggest it is time to revisit this approach to decision-making regarding CPR in the perioperative setting (Anesthesiology 2021;135:781-7). Our commitment to respecting patient autonomy and patient-centered care entails that we strive to identify patients at risk of poor outcomes should they undergo perioperative CPR and to elucidate their preferences regarding resuscitation, irrespective of their existing or presumed code status.
CPR is more likely to be successful in the perioperative setting compared to other in-hospital or out-of-hospital contexts, but mounting evidence suggests that outcomes in a high-risk subset of surgical patients may be less favorable. For example, one recent study found an 11- and 32-fold increase in 30-day mortality following CPR for perioperative cardiac arrest among patients with ASA Physical Status IV and V, respectively (compared to ASA I and II patients) (PLoS One 2020;15:e0225939). A previous investigation demonstrated survival to discharge of 17% for ASA IV and 8% for ASA V patients following perioperative CPR (JAMA Surg 2013;148:14-21). Age and functional status also predict vulnerability to poor outcomes: survival to discharge (at any functional status) was 14% in patients greater than 85 years of age, 15% in partially dependent patients, and 11% in totally dependent patients (JAMA Surg 2013;148:14-21).
Elderly patients with functional limitation frequently have significant comorbidities, including frailty, a condition of diminished physiologic reserves predisposing to worse outcomes in a variety of settings (Anesth Analg 2020;130:1450-60). Data from other settings suggest even moderate frailty is associated with dismal odds of survival following CPR and increased incidence of extubation failure, need for tracheostomy, and discharge to long-term institutional care (Resuscitation 2019;143:208-11; Resuscitation 2020;146:138-44; Intensive Care Med 2019;45:1742-52). In light of these data, we submit that it is not appropriate to assume that our most vulnerable elderly patients really “want everything done” based on the fact that they do not have a directive limiting treatment. The available evidence does not necessarily support the view that perioperative CPR is “inappropriate” in high-risk patients, but it does suggest that its appropriateness depends on patient-centered consideration of its risks and benefits.
In a recent issue of Anesthesiology, we and a team of authors spanning anesthesiology, surgery, critical care medicine, geriatrics, law, and palliative care articulate an expanded approach to decision-making regarding CPR in older surgical patients (Anesthesiology 2021;135:781-7). We argue that the decision to engage a patient about their preferences should not hinge on whether a patient has a DNR order or other directive limiting treatment in place; like other elements of compassionate, ethical care, it should be tailored to the characteristics, circumstances, and preferences of the individual patient.
We propose an expanded approach to decision-making regarding perioperative CPR in older surgical patients based not on existing or presumed code status, but on patient-specific preferences and vulnerabilities. When caring for patients 75 years of age or greater, anesthesiologists should be attuned to documentation or evidence of conditions that indicate vulnerability to complications and poor outcomes after CPR, including age 85 or greater, ASA Physical Status IV or greater, functional impairment, and frailty. When possible, the presence of these conditions should trigger engagement with patients (or their surrogates in cases of decisional incapacity) to clarify preferences regarding perioperative resuscitation (Figure). This process should be multidisciplinary, and ideally should include not only the surgeon/proceduralist and anesthesiologist, but also a physician with a longitudinal relationship with the patient (e.g., primary care physician, geriatrician, or other medical specialist). Of course, many circumstances will make attempts to clarify code status in high-risk patients impractical or impossible. In these cases, “full code” should remain the default (Anesthesiology 2021;135:781-7).
Our proposals are designed to be compatible and synergistic with initiatives from the American College of Surgeons, the American Geriatrics Society, and the Society for Perioperative Assessment and Quality Improvement as they promote screening for geriatric-specific vulnerabilities, shared decision-making, and interdisciplinary care planning (asamonitor.pub/3xruCiE; J Am Coll Surg 2012;215:453-66; J Clin Anesth 2018;47:33-42). The barriers to implementation are not insignificant. Surmounting them will require not only the will of professional societies like ASA, but also multidisciplinary efforts at institutional levels to develop practices that are sensible in the context of local culture, resources, and infrastructure.
Because there is a growing, identifiable subset of surgical patients who are less likely to survive and more likely to suffer complications and changes in quality of life after perioperative CPR, we should not assume that all elements of resuscitation are concordant with high-risk patients’ goals and preferences. Instead, we favor implementing an approach to perioperative decision-making regarding CPR that is focused on patient-specific preferences and vulnerabilities. Doing so will take time and a multidisciplinary effort, but is an essential step toward realizing “the traditional medical practice of responding individually and compassionately to the unique needs of each patient” (Anesthesiology 1991;74:606-8).