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## Complete Summary

#### GUIDELINE TITLE

Do-not-resuscitate orders for pediatric patients who require anesthesia
and surgery.

#### BIBLIOGRAPHIC SOURCE(S)

Fallat ME, Deshpande JK. Do-not-resuscitate orders for pediatric
patients who require anesthesia and surgery. Pediatrics 2004
Dec;114(6):1686-92. \[31 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15574636)

#### GUIDELINE STATUS

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years
by the authoring body, at which time a recommendation is made that the
policy be retired, revised, or reaffirmed without change. Until the
Board of Directors approves a revision or reaffirmation, or retires a
statement, the current policy remains in effect.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Conditions requiring anesthesia and surgery

#### GUIDELINE CATEGORY

Management

#### CLINICAL SPECIALTY

Anesthesiology\
Family Practice\
Pediatrics\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Hospitals\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide recommendations for the use of do-not-resuscitate orders for
pediatric patients who require anesthesia and surgery

#### TARGET POPULATION

Pediatric patients with preexisting do-not-resuscitate orders who
require anesthesia and surgery

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Informed consent

    -   \"Required reconsideration\" of do-not-resuscitate (DNR) orders

    -   Patient/parent education/discussion

2.  Documentation in medical record

    -   Patient/parent wishes

    -   Interval of DNR suspension if appropriate

3.  Communicate DNR orders to relevant staff and identify staff who are
    willing to honor the DNR request

4.  Referral to ethics committee as appropriate

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Searches were done using PubMed and specialty society surveys.

#### NUMBER OF SOURCE DOCUMENTS

Two surveys

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)\
Subjective Review

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Informed Consent**

To respect the child\'s and family\'s wishes, physicians must obtain
informed permission from a parent or surrogate before a child can
undergo any medical intervention including surgery and resuscitation.
Ordinarily, resuscitation efforts do not require informed consent,
because they are deemed emergency interventions and consent is implied.
However, terminally ill or severely disabled children and their parents
are often confronted with the decision of whether resuscitation should
be attempted in the event the child\'s underlying disease results in
cardiopulmonary arrest.

Customarily, physicians will approach the parent or surrogate about
instituting a do-not-resuscitate (DNR) order when it is felt that
resuscitation of the child would not be beneficial and would only
prolong the time to death. When a parent or surrogate consents to a DNR
order, it is under the assumption that cardiopulmonary arrest will be a
direct consequence of the child\'s underlying disease. Surgery and
anesthesia constitute a change in the child\'s medical status, because
they introduce additional risks to the patient. Because surgeons and
anesthesiologists are rarely involved in the original DNR decision, they
cannot be certain that the implications of the DNR status in the
perioperative setting were discussed with the patient\'s parent (or
other surrogate).  Therefore, the parent or surrogate, the surgeon, and
the anesthesiologist should reevaluate the DNR order for a child who
requires an operative procedure. This reevaluation process has been
called \"required reconsideration\" and should be incorporated into the
process of informed consent for surgery and anesthesia. Discussions
regarding consent under these circumstances should be initiated by
attending staff, particularly in hospitals with residency teaching
programs in which residents may be routinely involved in the consent
process.

The surgeon and anesthesiologist must approach the parents and child
with compassion. There is often no previous relationship established
between the patient, parents, and surgical team, precluding a brief
preoperative assessment. \"Active listening\" is essential. The parent
or surrogate should be asked about specific interventions and their
understanding of the relative merits of each of these interventions
during resuscitation (see Table 3 in the original guideline document).

Airway management should be determined by what is mandated by the
child\'s condition and the surgical procedure. Specific prohibition of
tracheal intubation is problematic, and beliefs and concerns must be
carefully elicited and discussed. Exceptions to the injunctions against
intervention should be specifically noted in the patient\'s medical
record. The parent may agree to a temporary suspension of the DNR order
during the perioperative period. If so, the temporal end point to the
DNR suspension needs to be recorded as well. If an agreement cannot be
obtained after thorough discussion, the wishes of the informed parent or
surrogate must prevail. In some cases, the parents may feel that the
burden of a therapy is not worth the potential benefits and decline the
procedure. When an individual physician feels that the parent\'s wishes
are inconsistent with his or her medical, ethical, or moral views, the
physician should withdraw from the case after ensuring continuity of
care (American Academy of Pediatrics \[AAP\], 1994) and could consider
consulting the institutional ethics committee.

**Role of the Surgeon**

The following are operative interventions that might be considered for a
pediatric patient with a DNR order:

1.  Provision of a support device that will enable the child to be
    discharged from the hospital (e.g., gastrostomy tube or
    tracheostomy).

2.  Urgent surgery for a condition unrelated to the underlying chronic
    problem (e.g., acute appendicitis in a terminal cancer patient)

3.  Urgent surgery for a condition related to the underlying chronic
    problem but not believed to be a terminal event (e.g., a pathologic
    fracture or bowel obstruction).

4.  A procedure to decrease pain

5.  A procedure to provide vascular access.

It is the duty of the operating surgeon to discuss risks of a procedure
with the parent or other surrogate of any pediatric patient, including
how the patient\'s condition might influence the risk of anesthesia.

It is expected that the surgeon will advise parents or other surrogates
and the child (if developmentally appropriate) regarding operative risks
and benefits and advocate a policy of required reconsideration of
previous DNR orders. The results of all discussions should be documented
in the patient\'s medical record. The surgeon should also ultimately
convey the patient\'s wishes to the members of the entire operating room
team, help operating team members understand the patient\'s or
surrogate\'s wishes, and find alternate team members to replace
individuals who disagree with the patient\'s or surrogate\'s wishes.
With children, the difficulty arises when there is no one who is willing
to honor a family\'s wish to continue the DNR status during the
anesthesia and surgery. Stalemates such as this should be referred to
the ethics committee of the institution.

**Role of the Anesthesiologist**

Anesthesiologists have the duty to inform the parent or other surrogate
of the risks and potential benefits of intraoperative resuscitation.
Required reconsideration as part of the process of informed consent for
anesthesia eliminates ambiguities and misunderstandings associated with
patients who have DNR orders by providing anesthesiologists with the
opportunity to educate the parent (or other surrogate) to become
familiar with their values and perceptions of the child\'s quality of
life and together clarify how the child\'s DNR order should be
interpreted perioperatively. By giving parents or surrogates and
clinicians the option of deciding from among full resuscitation,
limitations based on procedures, or limitations based on goals, the
child\'s needs are individualized and better served. Regardless of the
decision made by the parent or other surrogate, the individual acting on
behalf of the child must be readily available for consultation during
the procedure.

**If DNR Orders are Suspended: Qualification of Perioperative Interval**

If the family or medical personnel involved in a child\'s care choose to
suspend DNR orders during anesthesia and surgery, it is necessary to
define the duration of suspension (Clemency & Thompson, 1997). The
physiologic effects of anesthesia and surgery rarely terminate at the
end of the procedure, but the duration thereafter depends on the
anesthetic technique used and the type of surgical procedure performed.
The acute effects of most anesthetic medications generally resolve
within several hours or 1 day after surgery, and most anesthesiologists
visit the patient the day after a surgical procedure and document
recovery status in the patient record. Recovery of respiratory function
after surgery depends on preoperative pulmonary function, chronicity of
illness, and length of the procedure. Some patients will experience
cardiopulmonary arrest during or immediately after surgery, which may be
the result of an acute and reversible complication. It is appropriate to
use mechanical ventilation after surgery as long as the patient
continues to show significant and sustained improvement in pulmonary
function. Once the patient ceases to recover or deteriorates, withdrawal
of ventilatory support should be considered. Generally speaking, the
suspension of DNR orders should continue until the postanesthetic visit,
until the patient has been weaned from mechanical ventilation, or until
the primary physician involved in the patient\'s care and the family
agree to reinstate the DNR order.

The surgeon and anesthesiologist should feel comfortable, and should be
allowed, to reinstate a DNR order intraoperatively through consultation
with the family under certain conditions. For example, if cardiac arrest
occurs during surgery and it is apparent that the arrest is the result
of an irreversible underlying disease or complication and that
cardiopulmonary resuscitation (CPR) would only allow continued
deterioration, the DNR order should be reinstated. If resuscitation
measures are withheld and intraoperative arrest occurs, such a death
should be classified as \"expected\" for quality assurance purposes
rather than \"unexpected.\" Expected deaths do not require mandatory
quality assurance review (Igoe, Cascella, & Stockdale, 1993; Youngner,
Cascorbi & Shuck, 1991)

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=6193)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   This guideline is intended to help clinicians appropriately manage
    pediatric patients with preexisting do-not-resuscitate orders who
    require anesthesia and surgery.

-   By giving parents or other surrogates and clinicians the option of
    deciding from among full resuscitation, limitations based on
    procedures, or limitations based on goals, the child\'s needs are
    individualized and better served.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**Implementing \"Required Reconsideration\"**

Hospitals are encouraged to develop and maintain written policies
permitting the forgoing of life-sustaining treatment of patients,
including children, in appropriate circumstances. Once a DNR order is in
place according to accepted standards, it is important that it be
reviewed before surgery to determine applicability in the operating room
and the postoperative recovery period. Hospitals wishing to develop a
\"required reconsideration\" policy may want to address the following
elements:

-   Include in the discussion with a child\'s parent or other surrogate
    information about the likelihood of requiring resuscitative
    measures, a description of these measures and their reversibility,
    the chance of success, and possible outcomes with and without
    resuscitation. Establish an agreement about what, if any,
    resuscitative measures will be instituted during the procedure.

-   Make the decision to uphold or suspend a DNR order on the basis of
    the planned procedure, the anticipated benefit for the child, and
    the likelihood of patient compromise as a result of the procedure.

-   Document the salient features of the physician-family discussion in
    the medical record.

-   Communicate plans to honor an intraoperative DNR order among
    relevant staff.

-   Require any physician or other health care professional who is
    unwilling to honor a family\'s refusal of resuscitation to withdraw
    from the case and allow others to assume care. The withdrawing
    physician or health care professional should make a conscientious
    effort to identify another physician who is willing to honor the DNR
    request. (American Academy of Pediatrics, Committee on Bioethics,
    1994)

-   Recognize that a patient\'s or surrogate\'s decision to refuse
    intraoperative resuscitation can be compatible with the provision of
    therapeutic measures to treat conditions other than arrest. This
    decision does not necessarily imply limits on other forms of care
    such as intensive care.

-   If the family chooses to rescind the DNR order in the operating room
    and arrest occurs with resuscitation, but the patient\'s process of
    dying has only been prolonged, make a provision to discuss
    withdrawal of life support after a determined amount of time.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

End of Life Care\
Getting Better\
Living with Illness

#### IOM DOMAIN

Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Fallat ME, Deshpande JK. Do-not-resuscitate orders for pediatric
patients who require anesthesia and surgery. Pediatrics 2004
Dec;114(6):1686-92. \[31 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15574636)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Dec

#### GUIDELINE DEVELOPER(S)

American Academy of Pediatrics - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Pediatrics

#### GUIDELINE COMMITTEE

Section on Surgery\
Section on Anesthesia and Pain Medicine\
Committee on Bioethics

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Section on Surgery, 2004-2005*: Donna A. Caniano, MD, *Chairperson*;
Richard R. Ricketts, MD; Brad W. Warner, MD;

Kurt D. Newman, MD; Michael D. Klein, MD; Ann M. Kosloske, MD, Past
Section Chairperson; Richard Andrassy, MD, Past Section Chairperson;
Richard Azizkhan, MD, Past Section Chairperson; Thomas R. Weber, MD,
Past Section Chairperson

*Consultants*: Jane Goldsmith, PhD; Katia G. Santos, MD

*Staff*: Chelsea Kirk

*Section on Anesthesiology and Pain Medicine, 2004-2005*: Thomas
Mancuso, MD, *Chairperson*; Joseph Cravero, MD; Constance Houck, MD;
Zeev Kain, MD; Lynne Maxwell, MD; Robert Valley, MD; Rita Agarwal, MD;
Lynne Ferrari, MD, Past Section Chairperson; Patty Davidson, MD, Past
Section Executive Committee Member; Jayant K. Deshpande, MD, Past
Section Executive Committee Member

*Staff*: Kathleen Kuk Ozmeral

*Committee on Bioethics, 2004-2005*: Jeffrey R. Botkin, MD, MPH; Douglas
S. Diekema, MD, MPH; Mary E. Fallat, MD; Eric D. Kodish, MD; Steven R.
Leuthner, MD; Lainie Friedman Ross, MD, PhD; G. Kevin Donovan, MD, MLA;
John T. Truman, MD, MPH, Past Committee Member; Benjamin S. Wilfond, MD,
Past Committee Member

*Liaisons*: Christine E. Harrison, MD, Canadian Paediatric Society; Neil
W. Boris, MD, American Academy of Child and Adolescent Psychiatry;
Marcia Levetown, MD, American Board of Pediatrics; Arlene J. Morales,
MD, American College of Obstetricians and Gynecologists; Alessandra
(Sandi) Kazura, MD, Past Committee Liaison; Ernest F. Krug, III, MDiv,
MD, Past Committee Liaison; Michael K. Lindsay, MD, Past Committee
Liaison

*Consultant*: Dena S. Davis, JD, PhD

*Staff*: Alison Baker, MS

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years
by the authoring body, at which time a recommendation is made that the
policy be retired, revised, or reaffirmed without change. Until the
Board of Directors approves a revision or reaffirmation, or retires a
statement, the current policy remains in effect.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Academy of Pediatrics
(AAP) Policy Web
site](http://pediatrics.aappublications.org/cgi/content/full/114/6/1686).

Print copies: Available from American Academy of Pediatrics, 141
Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on February 4, 2005. The
information was verified by the guideline developer on March 15, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest
Point Blvd, Elk Grove Village, IL 60007.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008