Some providers consistently suspend patients’ documented do-not-resuscitate (DNR) orders during and after transcatheter aortic valve replacement (TAVR) procedures, according to a new study published in the Journal of the American Geriatrics Society.[1] The findings not only raise ethical concerns, but also skew mortality data across different programs.
The inconsistent application of DNR wishes became clear when the paper’s authors interviewed 52 TAVR coordinators in Washington and California. Out of 50 coordinators whose programs had performed TAVR in the previous calendar year, only six said that their programs respect patients’ documented DNR wishes during the entire procedure and its aftermath. Thirty-nine programs (78% of the respondents) suspended DNR status until after the procedure was complete, and sometimes up to 30 days beyond. The remaining four programs said they did not have a consistent practice and one said that they simply do not consider performing TAVR on patients with DNR status.
“This is significant because TAVR volumes will continue to grow because of the procedure’s minimally invasive nature and because severe aortic stenosis is common among older people. People are living longer, often with more chronic conditions. So more older patients— the ones likely to have DNRs—will want this procedure,” said lead author Gwen Bernacki, MD, an assistant professor of cardiology at the University of Washington School of Medicine, in a statement about the study.
Of the 39 programs that suspend patients’ DNR status during the actual TAVR procedure, 38% said they reinstated DNR within 48 hours of the surgery’s completion; 44% reinstated DNR upon discharge; and 18% did not reinstate DNR until 30 days or more after the procedure.
Many respondents noted that their programs actually lack a formal written procedure on whether to resuscitate patients with a DNR preference. While their responses describe their usual process, only 26% of program coordinators said they have formal guidance in place.
“Among programs categorically reversing patients' DNR status, the rationale for differing lengths of time to reinstatement reflect divergent views on accountability and reporting requirements,” the study’s authors wrote.
The American Society of Anesthesiologists and the American College of Surgeons both state that automatic suspension of DNR status conflicts with patients’ rights to self-determination, the authors noted.
In addition to ethical problems, the inconsistent application of DNR preferences and subsequent reporting makes it difficult for researchers to gain an accurate understanding of procedural outcomes and to compare outcomes across programs.
“One great strength of cardiology is that the field relies strongly on research, including randomized controlled trials and outcomes studies, to determine the best ways to treat disease. So it was very surprising to see such variability in clinical decision-making among the programs we studied,” Bernacki said.
To address both moral aspects and research-related concerns, Bernacki suggests that a governing group could create “standardized, patient-centered guidance” with input from stakeholders, including practitioners from relevant fields as well as patients and their families. Standard guidelines could remove some of the pressure for interventional cardiologists to achieve successful outcomes for their programs, with Bernacki noting that patient mortality data is collected in national outcome registries and negatively affects program metrics.
“Standardizing doesn't mean you can't have some flexibility and deliver care that is truly person-centered. But it means that the approach you take with patients is the same at hospitals across the country. Patients should be a part of a process that most people think is reasonable, and certainly not one that is at the least, on the surface, somewhat random,” she said.