A sixty-two-year-old woman was admitted to the hospital because of an inability to walk secondary to severe pain in the left hip as well as a large, fungating infiltrating ductal carcinoma of the breast. Computed tomography demonstrated multiple areas of osseous metastases. The left femoral neck and acetabulum were at risk for impending fracture. In discussing the diagnosis, prognosis, and treatment with the patient, she indicated that she wanted treatment that would slow and palliate the cancer, including chemotherapy and hormonal therapy. She did not wish for cardiopulmonary resuscitation or mechanical intubation to be performed. A do-not-resuscitate order was entered in her chart. However, she agreed to surgery and radiation therapy to stabilize the metastatic lesion in the femur, since it could improve her mobility and her overall quality of life.
The average age of an orthopaedic patient undergoing hip replacement in the United States is sixty-six years1. In this century, the growth rate of the elderly population (individuals sixty-five years old and over) has greatly exceeded the growth rate of the population of the country as a whole. The elderly population has increased by a factor of eleven, from three million in 1900, to thirty-three million in 1994. During the same time period, the total population, including those who are less than sixty-five years old, tripled. Under the current U.S. Census Bureau's projections, the number of individuals sixty-five years old and over is expected to more than double to eighty million by the middle of this century. Roughly one in eight Americans was elderly in 1994, and about one in five will be elderly by the year 2030. According to the U.S. Census Bureau, one of every twenty-six baby boomers, i.e., members of the generation born from 1946 through 1964, will reach the age of 100 years2.
In the context of this "graying of America," increasing numbers of people have multiple life-limiting diagnoses, such as cancer, chronic obstructive pulmonary disease, and cardiovascular disease, making their risks for surgery more complex. Thus, the discussion of advance directives and, specifically, cardiopulmonary resuscitation, especially in the perioperative setting, has become more relevant. In a survey of 102 orthopaedic surgery attending and resident physicians that assessed their knowledge of medical ethics, the level of knowledge regarding issues in end-of-life care was deemed by the authors to be lower than that of other ethical issues3. There was some confusion regarding the meaning of a do-not-resuscitate order as well as misconceptions regarding advance directives.
Several questions arise with regard to resuscitation issues. What does resuscitation entail, what does a do-not-resuscitate order mean, and what are its limitations? If the patient has a do-not-resuscitate order, should it be suspended for surgery? How does one discuss resuscitation issues with a patient? What should be done if a patient has a perioperative complication such as sepsis or an allergic reaction that involves respiratory failure or cardiac arrest? These questions are addressed in the following discussion.
In a study of eighteen patients with do-not-resuscitate orders, fifteen would agree to some form of surgery to achieve some specific goal, such as decreasing pain, enhancing quality of life, or treating a problem unrelated to the disease process. Some patients indicated that they believed the do-not-resuscitate order should be suspended during the perioperative period23. Several patients indicated that if the do-not-resuscitate order was suspended during surgery, they would want a time limit on the suspension. It was clear that patients had different intents and perceptions of what was best for them. The concerns of being kept alive on a machine, and the emotional and economic consequences of prolonged care, were often discussed by these patients23.
The issue of do-not-resuscitate orders in the operating room was first addressed in the anesthesia literature in the early 1990s24,25. Prior to that time, it was essentially assumed that do-not-resuscitate orders were automatically reversed in the operating room26. In 1994, the American College of Surgeons (ACS) published guidelines regarding the management of these patients in the perioperative period. Many hospitals have developed policies that specifically address this issue. According to the ACS guidelines, the best approach is a policy of "required reconsideration" of previous do-not-resuscitate orders. Table I lists the risks and benefits of a suspension of do-not-resuscitate orders in the perioperative period7,9,27. Preexisting do-not-resuscitate orders must be reviewed with the patient and then affirmed, suspended in their entirety, or modified.
Communication regarding the goals of care is critical with respect to this issue. The patient and/or his or her family and the responsible clinical team should discuss the specific risks of surgery and the approach to potential life-threatening problems during the perioperative period. The team should include the surgeons, anesthesia personnel, and nurses involved in the patient's care. These discussions may lead to any of the following: full resuscitation in the operating room regardless of the clinical scenario, goal-directed resuscitation if only deemed temporary and reversible, or procedure-directed resuscitation such as cardioversion26,27. Patients should be made aware that if resuscitation occurs and results in an untoward outcome, such as a persistent coma or a vegetative state, then life-sustaining measures can be discontinued. The results of such discussions should be carefully documented in the record25.
In the introductory case, the patient's do-not-resuscitate order was rescinded during surgery and the perioperative period. Discussion with the patient centered on measures to be taken in the perioperative period if she did not stabilize after surgery. It was thought that an aggressive supportive approach, such as temporary intubation, would be appropriate if postoperative complications, such as sepsis, pneumonia, or pulmonary embolus, occurred. However, if she remained unstable after a week, withdrawal of aggressive support would be considered. This once again demonstrates the importance of ongoing communication between providers and the patient and his or her loved ones during the perioperative period.
The discussion of resuscitation status, especially in the perioperative setting, is an important aspect of orthopaedic patient care. Communication with the patient and/or surrogate regarding the goals of care and education about resuscitation form the foundation for such discussions and, when done effectively, will enhance patient care and professional satisfaction. Simply stated, clinicians should not assume that do-not-resuscitate orders apply to other care interventions and should focus on the patient or surrogate for guidance with regard to interventions that are acceptable to the patient.