Advanced Directive and DNR Status Confirmation

Guidelines:

• Specific desires of the patient regarding care
• Can be completed by family if patient incompetent
  • If family, allows for conversations intraop
• Often suspended or modified for surgery
  • Get details!

Considerations:

• Suspension of DNI, but what if they can’t wean post-operatively
• Ethical committee present in most hospitals
• If patient competent, usually assign a decision maker for details not included in the advanced directive.
• Anticipate that every surgery could become long term intubation
• Capabilities of code in OR are near limitless, ensure patients understand their decisions with provider

Nurse’s Role:

• Patient interview to verify wishes and presence of advanced directive
• Maintain contact information with decision maker or family
  • Often call immediately before or after rolling to establish contact
    • Waiting until after intubation to realize you don’t have advanced directive is far too late
• Patient advocacy
• Elevate concerns as warranted
  • Ethical committee, chaplain,tumor board

Pitfalls:

• Suspension of DNR/DNI not clear
• Reversible causes in OR not clarified
• Snowballs over time in ICU
• Nurse turnover
  • Physical copy!
• Family definition of“resuscitate”

Examples:

• Patient undergoing epigastric hernia repair has altered rhythm on monitor, with wishes of DNR/DNI (control slowly, consider causes, consider abandoning case for further decisions, cards consult)
• 22F in pre-op for chole has never considered advanced directives or end of life possibilities (physician discussion of risks of surgery, decision maker consideration, anticipate pain may alter competence)

Linchpins (Key Points):

• You cannot speak to your patient under anesthesia, so must understand their plan before induction and advocate accordingly