A Sunday Problem-Based Learning Discussion featured a freewheeling roundtable discussion of how to deal with a decompensating neonate in the O.R. when a do-not-resuscitate (DNR) order is in place for the newborn.

Led by Vidya Tinku Raman, M.D., Pediatric Anesthesiologist at Nationwide Children’s Hospital and Clinical Assistant Professor of Anesthesiology at The Ohio State University College of Medicine, Columbus, the discussion participants examined the case of a 1.5 kg ancephalic triplet sent to the O.R. from the neonatal intensive care unit (NICU) for removal of a choroid plexus.

By the time of the procedure, the neonate’s sibling with the same condition had already died in the NICU. The choroid plexus removal was scheduled for that sibling before death.

“In modern pediatric medicine, withdrawing and withholding care for dying patients is morally equivalent,” Dr. Raman said. “This is a difficult decision for the caregivers of the moribund infant in the NICU to make, but it is even more difficult for pediatric anesthesiologists to make in the operating room.”

In this case, the infant’s family felt further medical intervention should be tried even in the face of a high probability of death. “The role the pediatric anesthesiologist plays in this important end-of-life decision prior to the O.R. is not only awkward but also almost incidental,” she noted.

In the O.R., the DNR order may be rendered inappropriate and may need to be suspended. A DNR in place does not mean that other interventions may be withdrawn or withheld, she said.

The newborn was sent to the O.R. for surgery to ameliorate decreasing cerebral spinal fluid production. The infant decompensated during the operation and died four hours later. The outcome was not expected.

“The operation was performed so that the patient’s head size would not be excessive and home care would be possible. Informed parents are the rightful decision-makers in this circumstance. The counseling physician needs to help the parents make the decision. The surgeon may enter the decision-making process, but the anesthesiologist is either late to the process or never part of it,” Dr. Raman said.

The ASA Ethical Guidelines for the Anesthesia Care of Patients With Do-Not-Resuscitate Orders or Other Directives That Limit Treatment recommend a preoperative discussion of the DNR order among the primary care team, surgeon and family.

The guidelines also state that the administration of anesthesia necessarily involves some practices and procedures that might be viewed as “resuscitation” in other settings.

“Prior to procedures requiring anesthetic care, any existing directives to limit the use of resuscitation procedures (that is, DNR orders and/or advance directives) should, when possible, be reviewed with the patient or designated surrogate. As a result of this review, the status of these directives should be clarified or modified based on the preferences of the patient,” according to the guidelines.

Dr. Raman asked other members of her discussion group how they would address the DNR order in this case.

Natasha Broemling, M.D., Pediatric Anesthesiologist at British Columbia Children’s Hospital in Vancouver, said, “In two cases where we’ve had patients dying in the O.R., we’ve asked the family to come in to see the resuscitation efforts. We had discussed resuscitation with the family before starting the procedure and they were given the option to come into the O.R. if the procedure required resuscitation.”

Stacy Peterson, M.D., Assistant Professor of Pediatric Anesthesiology at the Medical College of Wisconsin Children’s Hospital in Milwaukee, said, “I would talk to the surgeon first to find out exactly what the procedure involves and why it needs to be done to get the patient home to the parents.”

Kylie Yates, M.D., Pediatrician Staff Specialist at St. George Hospital in Kogarth, Australia, said, “I think it’s the pediatrician’s responsibility who is caring for the patient to understand what the goals of the procedure are and make sure the family understands what those goals are.”

 

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