“[A]rming anesthesiologists with the tools to provide patient-centered, meaningful perioperative care has the potential to both increase goal-concordant care delivery and reduce clinician moral conflict, moral distress, and burnout.”

Although preoperative “required reconsideration” for individuals with pre-existing treatment limitations (i.e., do-not-attempt-resuscitation or do-not-resuscitate status) has been American Society of Anesthesiologists (ASA; Schaumburg, Illinois), American College of Surgeons, and Association of Perioperative Registered Nurses policy for the last two decades, evidence suggests that we follow it poorly.  Although intraoperative cardiac arrest is rare and return of systemic circulation occurs in 42 to 71% of cases, long-term patient outcomes can still be poor, particularly for certain patient subgroups.  For example, ASA Physical Status IV and V patients who sustain an intraoperative arrest have 11- and 32-fold increases in 30-day mortality, and only 14% of patients over the age of 85 who experience return of systemic circulation after an intraoperative cardiac arrest will survive to hospital discharge. Patients sustaining an intraoperative cardiac arrest with no, partial, or complete preoperative functional impairment still only have 25, 15, or 11% survival to hospital discharge, respectively. Moreover, even after “successful” hospital discharge after an intraoperative cardiac arrest, there are few to no data about key patient outcomes such as long-term functionality and/or quality of life. Given this concerning milieu, preoperative discussions clarifying a patient’s unique beliefs and goals of care are not only pertinent but essential for patients with pre-existing treatment limitations and/or for those at high risk of poor outcomes.

Preoperative discussions about goals of care are often informed by a patient’s pre-existing advance care planning documents. Advance care planning is defined as a “process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care”; advance care planning documents can include formal legal documents that are authorized through state laws, such as advanced directives or Physician Orders for Life-Sustaining Treatment; legal designation of a durable healthcare power of attorney, healthcare proxy, or surrogate decision maker; or informal “living wills” that specify a person’s preferences regarding use of life-sustaining treatments or other medical therapies. Although advance care planning documents were previously deemed an appropriate strategy for codifying patient wishes and educating surrogate decision-making, that narrative has markedly morphed over the last few years due to building concern and data suggesting significant limitations inherent to advance care planning such as utilizing a static document to delineate evolving treatment preferences, the nonlinear nature of end-of-life care, and a shift from explicit documentation of concrete preferences toward the designation of surrogates and promotion of better “in the moment” surrogate decision-making.  Given this evolving discussion and the poor effectiveness of required reconsideration, it is appropriate for perioperative thought leaders and professional societies to re-examine the recommended approach for management of perioperative patients who present with treatment limitations.

In this issue of Anesthesiology, Allen et al.  describe the challenges surrounding perioperative management of advance directives and other patient expressions of treatment limitations and provide a novel path forward informed by serious illness communication strategies.  Eschewing a one-size-fits-all required reconsideration approach and rooted in the broader ethical frameworks and norms that dictate practice in the United States today, they offer a novel, structured approach for evaluating the alignment of a patient’s advance directive with their perioperative care needs alongside the implications of perioperative complications for their postoperative course. The authors particularly highlight the need for anesthesiologists to engage with “upstream” clinicians, including surgeons, primary care, and palliative care clinicians, to fully contextualize the planned perioperative care plan within the patient’s broader values and trajectory.

In our experience, many anesthesiologists are concerned that conversations addressing goals of care are challenging and require more time than a brief preoperative encounter may offer. The work of Allen et al. has the potential to overcome these limitations, offering recommendations that promote a structured approach to these conversations. Moreover, a workgroup of the ASA Ethics Committee recently completed a survey of ASA members about their management of code status orders during the perioperative period which, when published, will offer additional insights into how anesthesiologists across the United States manage perioperative DNR orders in vivo and thus how those approaches can incorporate the recommendations of Allen et al.  Moreover, such patient-centered approaches could benefit not only the patients but also their anesthesiologists. Providing medical treatments deemed improper, ineffective, or harmful can be a significant contributor to medical practitioner moral distress and burnout.  Thus, arming anesthesiologists with the tools to provide patient-centered, meaningful perioperative care has the potential to both increase goal-concordant care delivery and reduce clinician moral conflict, moral distress, and burnout.

Perioperative management of patients with treatment limitations and/or who are at high risk of poor outcomes after a perioperative cardiac arrest requires both in-the-moment and longitudinal prognostication skills that are beyond the scope of practice for many anesthesiologists. Despite this and while acknowledging the limitations of advance care planning and required reconsideration, the perioperative period remains one of the key arenas in which advance care planning and better goal-informed conversations may add significant value. The extensive narrative review of Allen et al. provides a path forward by contextualizing code status within a patient’s more broadly defined wishes, identifying surrogate decision-makers who can aid with emergent and urgent decisions in the face of unexpected intraoperative decompensation, and building systems that proactively involve other key stakeholders and specialists. Such concrete and implementable interventions provide a path toward a future in which required reconsideration has evolved into a “triggered team talk” with a multidisciplinary, systematic approach to promote more frequent and comprehensive preoperative discussions to ensure better team-based, goal-informed, patient-centered perioperative care.