Editorial: Do-Not-Resuscitate Orders and Advance Directives—Existential Issues for Orthopaedic Patients with Life-threatening Conditions
The vast majority of orthopaedic procedures are elective, and end-of-life care represents only a small part of most practices. Orthopaedic traumatologists and musculoskeletal tumor specialists deal with death more frequently than the rest of us, and I have to imagine that most of us are content not to face existential issues with our patients very often.
But every orthopaedic surgeon who takes call will, as a matter of routine, treat one common life-threatening injury: Hip fracture. More than a quarter-million patients—mostly women—sustain hip fractures each year in the United States alone , and more women die from hip fractures than from breast and endometrial cancers combined [4, 14]. Men who experience hip fractures are even more likely to die within a year of the injury than are women . Although hip fracture surgery alone accounts for half of the in-hospital deaths that occur after orthopaedic surgery , it is not the only “routine” diagnosis that should prompt a conversation about end-of-life issues. For example, the in-hospital risk of death in a patient with septic arthritis from Staphylococcus aureus, a common-enough problem, is in the range of 5% to 13% [1, 17] comparable to or greater than the risk of mortality following hip fracture surgery, which has been estimated at 2% to 5% [2, 8, 19].
Because of this, every time an orthopaedist admits a patient to the hospital with a potentially life-threatening surgical condition, (s)he should explore two topics: Code status (including the do-not-resuscitate, or DNR, order), and, more broadly, the wishes expressed in the patient’s advance directive. In an article published this month in Clinical Orthopaedics and Related Research®, Drs. Dunn, Ahn, and Bernstein from the University of Pennsylvania suggest that care teams seldom perform this sort of care planning with their hip-fracture patients (DOI: 10.1007/s11999-015-4675-1) . This should be an easy problem to solve, and it is important that we solve it.
Unfortunately, how to handle end-of-life planning in general, and DNR in particular, causes confusion and tension among surgeons, internists, and anesthesiologists. It causes confusion because the term “resuscitate” is vague and easily misconstrued. In the operating room, resuscitation entails much more than chest compressions, which rarely are needed during surgery. At issue are all of the other more-common resuscitative interventions performed routinely during anesthesia in the older patient, including the use of vasopressors, anti-arrhythmic drugs, and endotracheal intubation. Dips in blood pressure, new-onset arrhythmias, and respiratory depression all occur frequently during (and in the days following) surgery, and often are iatrogenic. If the physicians who have induced these physiologic changes are prevented from reversing them, these providers quickly find themselves in an uncomfortable position. Indeed, because of this, some may opt not to provide surgical care to patients with DNR orders, perhaps denying those patients reasonable interventions. Or, as bad, providers may administer treatments during or after surgery that a patient would not have endorsed.
The topic causes tension because some patient-advocates believe that physicians who ask patients to rescind DNR orders in advance of surgery do so for self-interested reasons having to do with publicly tracked quality-of-care metrics . This is a common discussion topic on lay websites  and those sites’ portrayals of physicians and their motives are not always flattering . The Institute of Medicine’s extensive report about care systems and insurance issues pertaining to patients in end-of-life situations was silent on the kinds of incentives that payors might exert in this setting, although certainly this seems worthy of attention . Further complicating matters is that anesthesiologists do not concur about what exactly their obligations are. Viewpoints range from: “Most anesthesiologists find it untenable to be required to provide anesthesia to a patient yet be prohibited from resuscitating the patient from complications accompanying the delivery of anesthesia”  to “patients do not check their rights to self-determination at the OR doors … policies automatically suspending or upholding DNR orders in the OR [are] ethically suspect, and … rediscussion of the DNR order should occur, whenever possible, prior to undertaking surgery and anesthesia” .
Perhaps because of these disagreements, practice patterns vary widely, and large proportions of practitioners (18% of anesthesiologists, 34% of internists, and 38% of surgeons in one study) believe that DNR orders should automatically be suspended during surgery . Neither the American College of Surgeons  nor the American Society of Anesthesiologists  endorse that belief. Both suggest that a detailed conversation take place between the care team and the patient or the patient’s designee to define what sorts of resuscitative efforts the patient is willing to undergo during and after surgery.
While the DNR order during surgery is perhaps the most acute concern, numerous issues pertaining to end-of-life care should be discussed whenever one admits a patient with a potentially life-threatening condition to the hospital. Although patients or their designees often complete advance-directive paperwork upon hospital admission, the stress of the moment and the large volume of other papers that get signed as part of that process may result in patients not reading these documents carefully. Surgeons need to foster explicit, detailed, and informed conversations on this topic with patients and families. Absent these conversations, there is no certainty that the signed documents reflect the patient’s actual wishes, and the care team may not know what those wishes are. Any number of nuances and complexities can arise during a hospital stay, even when the operation itself goes smoothly. Dr. Bernstein’s paper in this month’s CORR® (DOI: 10.1007/s11999-015-4675-1)  suggests that we may not be addressing these complexities attentively enough.
Identifying the individual who will help make medical decisions on the patient’s behalf should the patient lose the capacity to do so;
Determining whether end-of-life planning has been done, verifying that the patient’s documents and previously expressed wishes about the topic reflect the patient’s current desires in light of the new diagnosis (these desires may change in the face of existential threat), becoming familiar with these wishes, and sharing the substance of this discussion with all members of the care team, and, perhaps most importantly;
Discussing exactly what “DNR” means in the context of the planned procedure(s); in many situations, the “DNR” order indeed should be modified or suspended for a period of time during and after surgery, but this should be done only in consultation with the patient or the patient’s designee.
How do you manage these challenges in your practice? Share your approaches with CORR’s readers in a letter to the editor, at EIC@clinorthop.org.