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.

Introduction

nd-of-life care discussions are challenging in any scenario, but when the patient is a child, conversations regarding do-not-resuscitate (DNR) orders become substantially more difficult. Even in situations of terminal illness, it is uncommon for a child to be made DNR status. A retrospective review of children who died from malignancy found that fewer than half of patients had a DNR order or physician orders for life-sustaining treatment in the final stages of their disease.¹ Review of hospice data has demonstrated that children on hospice are half as likely as adults to have a DNR order in place, and among a large cohort of pediatric hospice patients only 39% had DNR status.²

Surgeons are frequently asked to perform procedures in critically ill children and must weigh the risks of these interventions with the potential benefit for the patient. As many as 15% of adult patients with DNR orders undergo surgical procedures.³ In a more recent study, 63% of adult patients with a DNR order had nonemergent surgery and DNR status was deemed an independent predictor of poor surgical outcome.⁴ There is a paucity of similar data on DNR status among children undergoing surgery.

This study therefore aims to assess the prevalence of DNR orders in critically ill pediatric surgical patients, to better understand the current environment, and highlight opportunities for improvement in the care of the sick child.