Endoscopy in a do-not-resuscitate patient: Practical and ethical considerations

Editor’s Note: I am very excited to introduce a section to The New Gastroenterologist that will address topics in clinical medical ethics we frequently face as gastroenterologists. There are several inherent ethical issues in gastroenterology that are not often explicitly discussed, such as periprocedural code status, informed consent, transplantation, performance of endoscopy in the critically ill, and nutrition support in the setting of end of life care. Often the most difficult decisions we make as clinicians are fraught with ethical implications which can be daunting and difficult to navigate. The goal of this section is to address these issues in a case-based format to offer some guidance to young gastroenterologists grappling with similar scenarios.

This month’s issue features the inaugural piece for this series, written by Dr. Lauren Feld (University of Washington), which discusses a clinical scenario in which a patient with a preexisting do-not-resuscitate (DNR) order is about to undergo endoscopy. The article provides a systematic approach to periprocedural code status and highlights existing guidelines that are generally not well known among gastroenterologists.
 

Vijaya L. Rao, MD
Editor in Chief

 

An 89-year old female with history of heart failure with reduced ejection fraction, chronic obstructive pulmonary disease, and dementia is admitted to the intensive care unit (ICU) with melena and acute post-hemorrhagic anemia. The family member designated as the patient’s power of attorney (POA) agrees that her code status upon admission will be do-not-resuscitate and do-not-intubate (DNR/DNI) without plan for invasive procedures. However, she has continued overt bleeding with concomitant hemodynamic instability. The POA and ICU team are now asking for urgent endoscopic evaluation, but do not agree to temporary code reversal for the duration of the procedure.

This vignette highlights an important distinction between a patient’s goals of care and the code status. While these two terms are often erroneously used interchangeably, “code status” refers to a patient’s wishes in the event of cardiopulmonary arrest, while “goals of care” refers to a more comprehensive understanding of what care fits within a patient’s values. Patients or their families may still desire interventions such as procedures, but not wish to have a resuscitation attempt in the event of cardiopulmonary arrest. This leads to the commonly encountered clinical scenario in which a patient planning to undergo endoscopy has an active DNR order.

Frequently, DNR orders are temporarily rescinded prior to invasive procedures. There are several reasons this occurs. First, patients or decision makers may decide that the improved rates of survival in intraprocedural arrests changes their risk-benefit assessment about resuscitation procedures. Secondly, proceduralists may feel an ethical duty to resuscitate a patient if the cause of the arrest is considered iatrogenic and potentially reversible. In addition, proceduralists may worry about legal or professional risk if a patient suffers cardiopulmonary arrest during a procedure and an attempt at resuscitation does not occur.

While this is a frequently encountered clinical scenario, there is wide variation in clinical practice. This variation led to the creation of guidelines set forth by the American Society of Anesthesiologists in 1993 and subsequently adopted by the American College of Surgeons. These guidelines recommend a discussion between the physician and the patient prior to the procedure, utilizing shared decision-making around three options: 1) a full attempt at resuscitation; 2) a limited attempt at resuscitation defined with regard to specific procedures; and 3) a limited attempt at resuscitation defined with regard to the patient’s goals and values.

However, these guidelines are both not well known and frequently not applied amongst clinicians and ancillary staff. Patients are frequently told that they must reverse their DNR order to full code prior to undergoing endoscopy. Dissemination of a systematic approach to a patient with a DNR order who requires endoscopy is important to ensure patients have autonomy over their medical decision-making, while also ensuring that health care professionals feel comfortable with their decisions.

 

The first step when encountering this scenario is to ensure that the procedure is indicated in this particular patient. While guidelines and algorithms have a substantial role in deciding the appropriate work-up for a presenting complaint such as a presumed upper gastrointestinal bleed, the art of medicine lies in the role of the physicians to decide if an invasive procedure is indicated in their specific patients. This decision should be based on the patients’ presenting clinical scenario, their overall comorbidities, their values, and their goals of care.

As the medical complexity of the patient increases, the risks of the procedure increase and it is ultimately up to the endoscopist to frame the informed consent conversation such that the patient and family understand the potential risks and benefits in their specific case.

With a patient who has a desire to avoid aggressive resuscitation attempts, the physician, patient, and family should weigh the risks and benefits of the procedure, and carefully examine if the indication is sufficient. For the patient outlined in the case, her dementia limits her decision-making capacity, and the clinical team is working with a surrogate decision-maker, her POA, to understand the patient’s wishes and goals. Her POA reports upon admission that invasive procedures may not be in line with her previously expressed values or in her best interest. However, with the development of an acute decompensation due to a presumed GI bleed, a potentially reversible cause, the POA requests an endoscopy to attempt to intervene. Occasionally, a patient with clear goals of care can have a change in these goals when a decompensation occurs. The gastroenterologist should assess if this represents a true desire for invasive procedures, or if this is a response to pressure from other members of the clinical team or family, or if palliative needs are not being met. In this patient, her POA desires an endoscopy because her likely upper GI bleed may be contributing to an acute decompensation, but does not wish for other aggressive measures if she should suffer cardiopulmonary arrest. Although upper endoscopy is a generally safe and well-tolerated procedure, this patient’s cardiopulmonary comorbidities increase the risk of the procedure; therefore, the gastroenterology team should proceed with a candid, detailed discussion of risks, benefits, and alternatives with the patient’s POA.

If the decision is made to proceed with endoscopy, the next step is to address the patient’s code status surrounding the procedure. This conversation should focus on three key goals: 1) allow the physician to gain understanding of the patient or surrogate’s perspectives on goals of care; 2) provide the patient or surrogate with an understanding of the risks and potential outcomes of the procedure, as well as resuscitation options; and 3) ultimately arrive at a mutual consensus regarding the patient’s periprocedural code status. Plans for postprocedural care should also be discussed.

While gastroenterology societies do not have specific guidelines surrounding this situation, there are several steps clinicians can take to ensure patient safety and autonomy are preserved:

 

• Physicians should avoid one-size-fits-all policies, such as the expectation that patients routinely return to full code for procedures.
• The patient and/or decision-makers should have a discussion regarding the risks during the procedure and potential reversibility of these risks.
• The patient should be presented with the option to either reverse to full code, refuse specific resuscitative measures such as defibrillation or intubation, or be allowed to explain his or her own views on goals of care and allow the procedural team to use their clinical judgment should an emergency arise.
• Physicians should be specific regarding the duration of the code status change. For example, in a patient who has reversed the code status to allow a full resuscitation attempt, the team and patient should discuss how long the patient will remain intubated after the procedure.
• This discussion should be documented carefully in the chart to assist with dissemination amongst the medical team.

This process will ensure that clear guidelines are defined such that everyone, including the patient’s potential decision makers, understand to what they are agreeing.

While physicians and care teams are primarily concerned with providing high-quality and individualized care to patients, it is true that concerns surrounding medicolegal risk are present. Careful informed consent and informed refusal conversations will reduce risk. Indeed, in a patient who has a DNR order, physicians are more likely to be at risk performing resuscitation efforts than withholding them. Communication between patients, families, and physicians remains the foundation for a trusting relationship and decreased litigation risk.

For this patient, engaging her POA in an honest and thorough discussion about her goals of care, as well as the risks of both performing and not performing the upper endoscopy are critical to her care. If her POA wishes to proceed with the procedure and have her remain DNR during the procedure, this should be documented and adhered to. Ultimately, the best outcome for this patient will occur with an individualized risk-benefit assessment and open, frequent communication among the care team and her POA.
 

Dr. Feld is a gastroenterology and hepatology fellow in the department of gastroenterology and hepatology, University of Washington, Seattle. She has no conflicts of interest.

Editor’s Note: I am very excited to introduce a section to The New Gastroenterologist that will address topics in clinical medical ethics we frequently face as gastroenterologists. There are several inherent ethical issues in gastroenterology that are not often explicitly discussed, such as periprocedural code status, informed consent, transplantation, performance of endoscopy in the critically ill, and nutrition support in the setting of end of life care. Often the most difficult decisions we make as clinicians are fraught with ethical implications which can be daunting and difficult to navigate. The goal of this section is to address these issues in a case-based format to offer some guidance to young gastroenterologists grappling with similar scenarios.

This month’s issue features the inaugural piece for this series, written by Dr. Lauren Feld (University of Washington), which discusses a clinical scenario in which a patient with a preexisting do-not-resuscitate (DNR) order is about to undergo endoscopy. The article provides a systematic approach to periprocedural code status and highlights existing guidelines that are generally not well known among gastroenterologists.
 

Vijaya L. Rao, MD
Editor in Chief

 

An 89-year old female with history of heart failure with reduced ejection fraction, chronic obstructive pulmonary disease, and dementia is admitted to the intensive care unit (ICU) with melena and acute post-hemorrhagic anemia. The family member designated as the patient’s power of attorney (POA) agrees that her code status upon admission will be do-not-resuscitate and do-not-intubate (DNR/DNI) without plan for invasive procedures. However, she has continued overt bleeding with concomitant hemodynamic instability. The POA and ICU team are now asking for urgent endoscopic evaluation, but do not agree to temporary code reversal for the duration of the procedure.

This vignette highlights an important distinction between a patient’s goals of care and the code status. While these two terms are often erroneously used interchangeably, “code status” refers to a patient’s wishes in the event of cardiopulmonary arrest, while “goals of care” refers to a more comprehensive understanding of what care fits within a patient’s values. Patients or their families may still desire interventions such as procedures, but not wish to have a resuscitation attempt in the event of cardiopulmonary arrest. This leads to the commonly encountered clinical scenario in which a patient planning to undergo endoscopy has an active DNR order.

Frequently, DNR orders are temporarily rescinded prior to invasive procedures. There are several reasons this occurs. First, patients or decision makers may decide that the improved rates of survival in intraprocedural arrests changes their risk-benefit assessment about resuscitation procedures. Secondly, proceduralists may feel an ethical duty to resuscitate a patient if the cause of the arrest is considered iatrogenic and potentially reversible. In addition, proceduralists may worry about legal or professional risk if a patient suffers cardiopulmonary arrest during a procedure and an attempt at resuscitation does not occur.

While this is a frequently encountered clinical scenario, there is wide variation in clinical practice. This variation led to the creation of guidelines set forth by the American Society of Anesthesiologists in 1993 and subsequently adopted by the American College of Surgeons. These guidelines recommend a discussion between the physician and the patient prior to the procedure, utilizing shared decision-making around three options: 1) a full attempt at resuscitation; 2) a limited attempt at resuscitation defined with regard to specific procedures; and 3) a limited attempt at resuscitation defined with regard to the patient’s goals and values.

However, these guidelines are both not well known and frequently not applied amongst clinicians and ancillary staff. Patients are frequently told that they must reverse their DNR order to full code prior to undergoing endoscopy. Dissemination of a systematic approach to a patient with a DNR order who requires endoscopy is important to ensure patients have autonomy over their medical decision-making, while also ensuring that health care professionals feel comfortable with their decisions.

 

The first step when encountering this scenario is to ensure that the procedure is indicated in this particular patient. While guidelines and algorithms have a substantial role in deciding the appropriate work-up for a presenting complaint such as a presumed upper gastrointestinal bleed, the art of medicine lies in the role of the physicians to decide if an invasive procedure is indicated in their specific patients. This decision should be based on the patients’ presenting clinical scenario, their overall comorbidities, their values, and their goals of care.

As the medical complexity of the patient increases, the risks of the procedure increase and it is ultimately up to the endoscopist to frame the informed consent conversation such that the patient and family understand the potential risks and benefits in their specific case.

With a patient who has a desire to avoid aggressive resuscitation attempts, the physician, patient, and family should weigh the risks and benefits of the procedure, and carefully examine if the indication is sufficient. For the patient outlined in the case, her dementia limits her decision-making capacity, and the clinical team is working with a surrogate decision-maker, her POA, to understand the patient’s wishes and goals. Her POA reports upon admission that invasive procedures may not be in line with her previously expressed values or in her best interest. However, with the development of an acute decompensation due to a presumed GI bleed, a potentially reversible cause, the POA requests an endoscopy to attempt to intervene. Occasionally, a patient with clear goals of care can have a change in these goals when a decompensation occurs. The gastroenterologist should assess if this represents a true desire for invasive procedures, or if this is a response to pressure from other members of the clinical team or family, or if palliative needs are not being met. In this patient, her POA desires an endoscopy because her likely upper GI bleed may be contributing to an acute decompensation, but does not wish for other aggressive measures if she should suffer cardiopulmonary arrest. Although upper endoscopy is a generally safe and well-tolerated procedure, this patient’s cardiopulmonary comorbidities increase the risk of the procedure; therefore, the gastroenterology team should proceed with a candid, detailed discussion of risks, benefits, and alternatives with the patient’s POA.

If the decision is made to proceed with endoscopy, the next step is to address the patient’s code status surrounding the procedure. This conversation should focus on three key goals: 1) allow the physician to gain understanding of the patient or surrogate’s perspectives on goals of care; 2) provide the patient or surrogate with an understanding of the risks and potential outcomes of the procedure, as well as resuscitation options; and 3) ultimately arrive at a mutual consensus regarding the patient’s periprocedural code status. Plans for postprocedural care should also be discussed.

While gastroenterology societies do not have specific guidelines surrounding this situation, there are several steps clinicians can take to ensure patient safety and autonomy are preserved:

 

• Physicians should avoid one-size-fits-all policies, such as the expectation that patients routinely return to full code for procedures.
• The patient and/or decision-makers should have a discussion regarding the risks during the procedure and potential reversibility of these risks.
• The patient should be presented with the option to either reverse to full code, refuse specific resuscitative measures such as defibrillation or intubation, or be allowed to explain his or her own views on goals of care and allow the procedural team to use their clinical judgment should an emergency arise.
• Physicians should be specific regarding the duration of the code status change. For example, in a patient who has reversed the code status to allow a full resuscitation attempt, the team and patient should discuss how long the patient will remain intubated after the procedure.
• This discussion should be documented carefully in the chart to assist with dissemination amongst the medical team.

This process will ensure that clear guidelines are defined such that everyone, including the patient’s potential decision makers, understand to what they are agreeing.

While physicians and care teams are primarily concerned with providing high-quality and individualized care to patients, it is true that concerns surrounding medicolegal risk are present. Careful informed consent and informed refusal conversations will reduce risk. Indeed, in a patient who has a DNR order, physicians are more likely to be at risk performing resuscitation efforts than withholding them. Communication between patients, families, and physicians remains the foundation for a trusting relationship and decreased litigation risk.

For this patient, engaging her POA in an honest and thorough discussion about her goals of care, as well as the risks of both performing and not performing the upper endoscopy are critical to her care. If her POA wishes to proceed with the procedure and have her remain DNR during the procedure, this should be documented and adhered to. Ultimately, the best outcome for this patient will occur with an individualized risk-benefit assessment and open, frequent communication among the care team and her POA.
 

Dr. Feld is a gastroenterology and hepatology fellow in the department of gastroenterology and hepatology, University of Washington, Seattle. She has no conflicts of interest.

Editor’s Note: I am very excited to introduce a section to The New Gastroenterologist that will address topics in clinical medical ethics we frequently face as gastroenterologists. There are several inherent ethical issues in gastroenterology that are not often explicitly discussed, such as periprocedural code status, informed consent, transplantation, performance of endoscopy in the critically ill, and nutrition support in the setting of end of life care. Often the most difficult decisions we make as clinicians are fraught with ethical implications which can be daunting and difficult to navigate. The goal of this section is to address these issues in a case-based format to offer some guidance to young gastroenterologists grappling with similar scenarios.

This month’s issue features the inaugural piece for this series, written by Dr. Lauren Feld (University of Washington), which discusses a clinical scenario in which a patient with a preexisting do-not-resuscitate (DNR) order is about to undergo endoscopy. The article provides a systematic approach to periprocedural code status and highlights existing guidelines that are generally not well known among gastroenterologists.
 

Vijaya L. Rao, MD
Editor in Chief

 

An 89-year old female with history of heart failure with reduced ejection fraction, chronic obstructive pulmonary disease, and dementia is admitted to the intensive care unit (ICU) with melena and acute post-hemorrhagic anemia. The family member designated as the patient’s power of attorney (POA) agrees that her code status upon admission will be do-not-resuscitate and do-not-intubate (DNR/DNI) without plan for invasive procedures. However, she has continued overt bleeding with concomitant hemodynamic instability. The POA and ICU team are now asking for urgent endoscopic evaluation, but do not agree to temporary code reversal for the duration of the procedure.

This vignette highlights an important distinction between a patient’s goals of care and the code status. While these two terms are often erroneously used interchangeably, “code status” refers to a patient’s wishes in the event of cardiopulmonary arrest, while “goals of care” refers to a more comprehensive understanding of what care fits within a patient’s values. Patients or their families may still desire interventions such as procedures, but not wish to have a resuscitation attempt in the event of cardiopulmonary arrest. This leads to the commonly encountered clinical scenario in which a patient planning to undergo endoscopy has an active DNR order.

Frequently, DNR orders are temporarily rescinded prior to invasive procedures. There are several reasons this occurs. First, patients or decision makers may decide that the improved rates of survival in intraprocedural arrests changes their risk-benefit assessment about resuscitation procedures. Secondly, proceduralists may feel an ethical duty to resuscitate a patient if the cause of the arrest is considered iatrogenic and potentially reversible. In addition, proceduralists may worry about legal or professional risk if a patient suffers cardiopulmonary arrest during a procedure and an attempt at resuscitation does not occur.

While this is a frequently encountered clinical scenario, there is wide variation in clinical practice. This variation led to the creation of guidelines set forth by the American Society of Anesthesiologists in 1993 and subsequently adopted by the American College of Surgeons. These guidelines recommend a discussion between the physician and the patient prior to the procedure, utilizing shared decision-making around three options: 1) a full attempt at resuscitation; 2) a limited attempt at resuscitation defined with regard to specific procedures; and 3) a limited attempt at resuscitation defined with regard to the patient’s goals and values.

However, these guidelines are both not well known and frequently not applied amongst clinicians and ancillary staff. Patients are frequently told that they must reverse their DNR order to full code prior to undergoing endoscopy. Dissemination of a systematic approach to a patient with a DNR order who requires endoscopy is important to ensure patients have autonomy over their medical decision-making, while also ensuring that health care professionals feel comfortable with their decisions.

 

The first step when encountering this scenario is to ensure that the procedure is indicated in this particular patient. While guidelines and algorithms have a substantial role in deciding the appropriate work-up for a presenting complaint such as a presumed upper gastrointestinal bleed, the art of medicine lies in the role of the physicians to decide if an invasive procedure is indicated in their specific patients. This decision should be based on the patients’ presenting clinical scenario, their overall comorbidities, their values, and their goals of care.

As the medical complexity of the patient increases, the risks of the procedure increase and it is ultimately up to the endoscopist to frame the informed consent conversation such that the patient and family understand the potential risks and benefits in their specific case.

With a patient who has a desire to avoid aggressive resuscitation attempts, the physician, patient, and family should weigh the risks and benefits of the procedure, and carefully examine if the indication is sufficient. For the patient outlined in the case, her dementia limits her decision-making capacity, and the clinical team is working with a surrogate decision-maker, her POA, to understand the patient’s wishes and goals. Her POA reports upon admission that invasive procedures may not be in line with her previously expressed values or in her best interest. However, with the development of an acute decompensation due to a presumed GI bleed, a potentially reversible cause, the POA requests an endoscopy to attempt to intervene. Occasionally, a patient with clear goals of care can have a change in these goals when a decompensation occurs. The gastroenterologist should assess if this represents a true desire for invasive procedures, or if this is a response to pressure from other members of the clinical team or family, or if palliative needs are not being met. In this patient, her POA desires an endoscopy because her likely upper GI bleed may be contributing to an acute decompensation, but does not wish for other aggressive measures if she should suffer cardiopulmonary arrest. Although upper endoscopy is a generally safe and well-tolerated procedure, this patient’s cardiopulmonary comorbidities increase the risk of the procedure; therefore, the gastroenterology team should proceed with a candid, detailed discussion of risks, benefits, and alternatives with the patient’s POA.

If the decision is made to proceed with endoscopy, the next step is to address the patient’s code status surrounding the procedure. This conversation should focus on three key goals: 1) allow the physician to gain understanding of the patient or surrogate’s perspectives on goals of care; 2) provide the patient or surrogate with an understanding of the risks and potential outcomes of the procedure, as well as resuscitation options; and 3) ultimately arrive at a mutual consensus regarding the patient’s periprocedural code status. Plans for postprocedural care should also be discussed.

While gastroenterology societies do not have specific guidelines surrounding this situation, there are several steps clinicians can take to ensure patient safety and autonomy are preserved:

 

• Physicians should avoid one-size-fits-all policies, such as the expectation that patients routinely return to full code for procedures.
• The patient and/or decision-makers should have a discussion regarding the risks during the procedure and potential reversibility of these risks.
• The patient should be presented with the option to either reverse to full code, refuse specific resuscitative measures such as defibrillation or intubation, or be allowed to explain his or her own views on goals of care and allow the procedural team to use their clinical judgment should an emergency arise.
• Physicians should be specific regarding the duration of the code status change. For example, in a patient who has reversed the code status to allow a full resuscitation attempt, the team and patient should discuss how long the patient will remain intubated after the procedure.
• This discussion should be documented carefully in the chart to assist with dissemination amongst the medical team.

This process will ensure that clear guidelines are defined such that everyone, including the patient’s potential decision makers, understand to what they are agreeing.

While physicians and care teams are primarily concerned with providing high-quality and individualized care to patients, it is true that concerns surrounding medicolegal risk are present. Careful informed consent and informed refusal conversations will reduce risk. Indeed, in a patient who has a DNR order, physicians are more likely to be at risk performing resuscitation efforts than withholding them. Communication between patients, families, and physicians remains the foundation for a trusting relationship and decreased litigation risk.

For this patient, engaging her POA in an honest and thorough discussion about her goals of care, as well as the risks of both performing and not performing the upper endoscopy are critical to her care. If her POA wishes to proceed with the procedure and have her remain DNR during the procedure, this should be documented and adhered to. Ultimately, the best outcome for this patient will occur with an individualized risk-benefit assessment and open, frequent communication among the care team and her POA.
 

Dr. Feld is a gastroenterology and hepatology fellow in the department of gastroenterology and hepatology, University of Washington, Seattle. She has no conflicts of interest.