Pediatric Perioperative DNR Orders: A Case Series in a Children’s Hospital

ABSTRACT [FROM JOURNAL]

Context: Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period is limited.

Objectives: Evaluate perioperative management of DNR orders at a tertiary care children’s hospital.

Methods: We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from 2/1/2016 – 8/1/2017. Using standardized case report forms, we abstracted the following from physician notes: (A) patient/family wishes with respect to the DNR, (B) whether pre-operative DNRs were continued, modified, or suspended during the perioperative period, and (C) whether life threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision making in the perioperative period.

Results: Twenty-three patients aged six days to 17 years had a DNR in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures, and suspended for fifteen (51%). Three children (13%) suffered life threatening events. We identified four time points where systematic reconsideration should be documented in the medical record, recommended personnel, and important discussion points at each time point.

Conclusion: Opportunities exist to improve how DNR orders are managed during the perioperative period.