Journal of Clinical Anesthesia (2012) xx, xxx–xxx

Original Contribution

Anesthesiologists’ familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting Michael Nurok MBChB, PhD (Clinical Associate Professor)a,b,⁎, Douglas S.T. Green MD (Clinical Assistant Professor)a,b , Mary F. Chisholm MD (Clinical Assistant Professor)a,b , Joseph J. Fins MD, MACP (Chief, Division of Medical Ethics; The E. William Davis, Jr, MD, Professor of Medical Ethics)c , Gregory A. Liguori MD (Clinical Professor; Anesthesiologist-in-Chief, Hospital for Special Surgery)a,b a

Department of Anesthesiology, Weill Cornell Medical College, New York, NY 10021, USA th Department of Anesthesiology, Hospital for Special Surgery, 535 East 70 St., New York, NY 10021, USA c Division of Medical Ethics, Weill Cornell Medical College, New York, NY 10021, USA b

Received 20 May 2013; revised 24 October 2013; accepted 13 November 2013

Keywords: Advance directives; Anesthesiologists; Compliance; End-of-life care; Guidelines; Operating room

Abstract Study Objective: To assess anesthesiologists’ familiarity with the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS) guidelines on Advance Directives in the perioperative setting. Design: Single-center, 4-question anonymous survey. Setting: Urban academic medical center. Subjects: Up to 34 subjects responded to each question. Measurements and Main Results: Familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting ranged from 45% to 100%. Conclusions: There was inadequate familiarity with components of the ASA and ACS guidelines on advance directives in the perioperative setting. Larger studies are required to assess anesthesiologists' familiarity with national society guidelines that directly affect patient care. Future work should investigate best practices for guideline implementation, and consequences of poor adherence to national guidelines. © 2012 Elsevier Inc. All rights reserved.

⁎ Correspondence: Michael Nurok, MBChB, PhD, Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021, USA. Tel.: 202-606-1206. E-mail address: [email protected] (M. Nurok). http://dx.doi.org/10.1016/j.jclinane.2013.11.011 0952-8180/© 2012 Elsevier Inc. All rights reserved.

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1. Introduction The do-not-resuscitate (DNR) order has become a right of passage to death for many patients receiving medical care [1]. Adopting best practices for patients with a DNR order is a duty for individual anesthesiologists, surgeons, clinical directors, and hospitals. The provision of anesthesia routinely results in a set of events that require measures that would be viewed as resuscitative in other circumstances. This situation presents a paradox for patients with a DNR order who require anesthesia. From the perspective of clinical ethics, a patient undergoing an operative procedure, who is also the subject of a DNR order, is making a positive claim for some care (receipt of surgery) while also asserting a negative right to be left alone (refusal of resuscitation). This mix of both positive and negative rights lead to confusion, especially when the consequences of one (surgery or induction) may lead to the need for the other (resuscitation) [2]. Until the 1990s, in order to address this paradox, DNR orders were routinely “reversed” or “suspended” when a patient required operative intervention or anesthetic management [3]. Recognizing that this approach may not respect a patient’s right to self-determination, in 1993 The American Society of Anesthesiologists (ASA) published a guideline to address DNR orders in the perioperative setting. The American College of Surgeons (ACS) later adopted a statement mirroring the ASA’s [4,5]. The current form of the ASA Guideline advocates reviewing the DNR order with the patient prior to the procedure and adopting one of three approaches: complete reversal and a full attempt at resuscitation, a limited attempt at resuscitation defined by procedures, or a limited attempt at resuscitation defined by the patient’s goals and values [4]. In all three approaches, the key to reconciling negative and positive rights is agreement on goals of care [2]. To assess this knowledge base, we conducted a brief, single-center survey of board-certified anesthesiologists to determine the accuracy of their understanding of the ASA and ACS guidelines on perioperative DNR. Our hypothesis was that there would be inadequate familiarity with the ASA and ACS guidelines.

2. Materials and methods Following approval from the Hospital for Special Surgery Institutional Review Board, an anonymous survey of attending anesthesiologists at an urban academic specialty orthopedic medical center was conducted during a faculty meeting. The survey was a “surprise” item on the agenda so that attendees would not have time to review the relevant guidelines. Four questions were answered using an audience response system; respondents were given approximately 90 seconds to answer each question. Response indicated

M. Nurok et al. consent to participate in the study. Respondents were given the opportunity to answer “true” or “false”. Following administration of the survey, faculty were sent an email with the correct answers, a copy of the ASA Guidelines, and a link to the ACS statement on DNR in the operating room (OR) (Table 1).

3. Results Thirty-six board-certified anesthesiologists ranging from their third decade to sixth decade of life, of whom 7 were women, were present at the meeting and eligible to respond. Twenty-four respondents were active ASA members during the period of the survey. There were 33 responses to the first question and 34 respondents to the second through fourth questions. Incorrect responses per question were 55% (18/33) for question 1, 29% (10/34) for question 2, 15% (5/34) for question 3, and 0% (0/34) for question 4.

4. Discussion Although there are data on anesthesiologist and surgeon perspectives on perioperative DNR practices [6–8], to our knowledge, none specifically cover familiarity with the ASA or ACS guidelines. One third of the respondents in this survey were not active ASA members; however, all were certified by the American Board of Anesthesiology, which has adopted a focus on advance directives in its Content Outline for which candidates are responsible. In addition, all respondents held licenses in the State of New York, which provides specific guidance on Advance Directives in the perioperative setting [9]. Table 1

Questions

Question 1. According to the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS), a patient with an existing Do Not Resuscitate Order should routinely have this order suspended prior to an operative intervention. 2. According to ASA and ACS, it is acceptable for health care institutions to adopt policies that automatically cancel a DNR order prior to an operation. 3. According to the ASA, the administration of anesthesia necessarily involves some practices and procedures that might be viewed as “resuscitation” in other settings. 4. According to the ASA, a patient may allow the anesthesiologist and surgical team to use clinical judgment in determining which resuscitation procedures are appropriate in the context of the situation and the patient’s stated goals and values as opposed to specifying which resuscitative interventions are acceptable (eg, chest compressions, defibrillation).

ASA and ACS guidelines familiarity Although this was a single-center survey at a specialty hospital and the results may not be generalizable, if respondents’ understanding of ASA policy was at all reflective of their personal views, then these results were consistent with other recent studies showing that 18% of anesthesiologists would routinely suspend a DNR order in the perioperative setting [7]. Additional published data confirmed that a concerning percentage of anesthesiologists and surgeons assume automatic suspension of a DNR order for patients requiring an operation [7,8,10,11]. Lack of awareness of ASA and ACS guidelines on perioperative DNR may compromise a patient’s right to self-determination. Lack of familiarity and compliance with society guidelines is common in medical practice [12]. Timmermans showed that although professional organizations develop practice guidelines as a tool for their members, they rarely require compliance [13]. Increasingly, states are adopting policies on resuscitation and patient self-determination. Indeed, our survey was prompted by the hospital’s updating of its policies for consistency with the 2010 New York State Family Health Care Decisions Act (FHCDA), which gives family members and domestic partners the right to make health care decisions on behalf of a patient [14]. The lack of familiarity with the ASA and ACS guidelines as noted in this single-center study raises concerns about the ability of anesthesiologists to fully empower patients and their surrogates with a DNR order. Larger national studies are required to gauge anesthesiologists’ familiarity with Society guidelines that directly affect patient care. Wachter and Pronovost, while lauding the “no blame” culture adoped by the patient safety movement, raise concern about whether this culture has led to a lack of accountability of physicians regarding practice [15]. Noncompliance with the present ethical guidelines potentially has serious implications for how patients die and should raise similar concerns. This study was limited by its single-center design and small size. The findings may not be representative of other anesthesiologists, academic medical centers, or hospitals. Further broad-based research is needed to address these questions. We were unable to determine from our data whether there was a relationship between ASA membership and guideline familiarity. This question should be addressed in future work. A number of solutions are possible. The ASA and ACS should ensure adequate educational campaigns for members regarding their guidelines. Anesthesia professional certifying boards can continue to focus educational practices to ensure familiarity with society guidelines on end-of-life care, as has been done with Internal Medicine Boards. Patient advocacy organizations similarly should create educational campaigns to ensure that patients understand and self-advocate for their rights. Finally, and perhaps most important, hospitals should

3 adopt clear policies consistent with national society perioperative DNR guidelines. In designing such policies, consideration should be given to routinely offering an ethics consultation for patients with an Advance Directive requiring surgery.

Acknowledgments The authors gratefully acknowledge the assistance of Dr. Victor Zayas, Mrs. Mary Hargett, and Mr. Mikhail Miller in obtaining data. The authors thank Ms. Kara Fields for her consultation on the manuscript. The authors also thank the faculty of the Department of Anesthesiology at The Hospital for Special Surgery for their participation in this research.

References [1] Burns JP, Edwards J, Johnson J, Cassem NH, Truog RD. Do-notresuscitate order after 25 years. Crit Care Med 2003;31:1543-50. [2] Fins JJ. A palliative ethic of care: clinical wisdom at life's end. Sudbury (MA): Jones and Bartlett Publishers; 2006. p. 189–92. [3] Cohen CB, Cohen PJ. Do-not-resuscitate orders in the operating room. N Engl J Med 1991;325:1879-82. [4] Ethical guidelines for the anesthesia care of patients with do-notresuscitate orders or other directives that limit treatment. Park Ridge (IL): American Society of Anesthesiologists; 2008. P. 1–2. In: https:// www.asahq.org/…/Standards%20Guidelines%20Stmts/ Ethical%20. [5] Statement of the American College of Surgeons on Advance Directives by Patients. “Do Not Resuscitate” in the operating room. Bull Am Coll Surg 1994;79:29. [6] Clemency MV, Thompson NJ. “Do not resuscitate” (DNR) orders and the anesthesiologist: a survey. Anesth Analg 1993;76:394-401. [7] Burkle CM, Swetz KM, Armstrong MH, Keegan MT. Patient and doctor attitudes and beliefs concerning perioperative do not resuscitate orders: anesthesiologists' growing compliance with patient autonomy and self determination guidelines. BMC Anesthesiol 2013;13:2. [8] Redmann AJ, Brasel KJ, Alexander CG, Schwarze ML. Use of advance directives for high-risk operations: a national survey of surgeons. Ann Surg 2012;255:418-23. [9] State of New York. DOH Memorandum 11/2/92. Health Facilities Series: H-27; RHCF-22; HHA-19; Hospice 10. [10] Clemency MV, Thompson NJ. “Do not resuscitate” (DNR) orders in the perioperative period–a comparison of the perspectives of anesthesiologists, internists, and surgeons. Anesth Analg 1994;78:651-8. [11] Schwarze ML, Redmann AJ, Alexander GC, Brasel KJ. Surgeons expect patients to buy-in to postoperative life support preoperatively: results of a national survey. Crit Care Med 2013;41:1-8. [12] Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458-65. [13] Timmermans S. From autonomy to accountability: the role of clinical practice guidelines in professional power. Perspect Biol Med 2005;48: 490-501. [14] New York State Bar Association. Special Edition: Implementing the Family Health Care Decisions Act. NYSBA Health Law Journal 2011;16(1). [15] Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med 2009;361:1401-6.

Anesthesiologists' familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting.

To assess anesthesiologists' familiarity with the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS) guidelines on Adv...
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