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Background: Pediatric palliative care (PPC) involves a multidisciplinary approach for the improved quality of life of children with life-limiting conditions. Many PPC patients present for palliative surgery, which involves procedures that manage symptoms but include risks that could result in catastrophic perioperative events. Determining a patient’s and family’s wishes regarding do-not-attempt-resuscitation (DNAR) order status can be a difficult topic to broach for providers who encounter these patients for the first time during the preoperative evaluation. A decision analysis tool may help in determining the need for preoperative DNAR communication.
Theoretical Framework:The theoretical framework that presents as the most obvious choice in the critical scenario of DNAR examination in pediatric palliative surgery (PPS) patients is that of decision theory, which deals with how to make optimal decisions in the face of uncertainty. The three presumptions of decision theory were used to create the decision analysis tool for the examination of DNAR status in PPS patients. Those presumptions involve the utility of possible outcomes that are uniquely weighed by decision makers according to circumstances and personal values.
Methods: The study design included a phase 1 with three semistructured interviews of invited experts for an initial needs assessment and critique of the DNAR decision analysis tool. Phase 2 entailed a filmed focus group with 17 invited experts who completed a pretest and posttest.
Results:When asked if a decision analysis tool would increase provider awareness of a need for DNAR communication, 81% of the focus group responded yes and 69% believe that it is possible to incorporate a standardized protocol for the identification of PPS patients in need of a DNAR status communication. When asked whether the DNAR decision analysis tool would be helpful in the participants’ future clinical practice, 75% responded yes, and 94% of the participants agreed that future education sessions would benefit the practitioners in their institution. Qualitative analysis results showed a central theme of “ideal world versus real world,” with five major themes of (1) population, (2) tool, (3) protocol, (4) education, and (5) barriers and seven subthemes of (1) risk, (2) assumptions, (3) urgency, (4) circumstances, (5) triggers, (6) relationship, and (7) conversation.
Conclusions: The conversation related to the DNAR status of the PPS patient is fraught with uncertain circumstances, risk, and urgency that can lead to assumptions. Lack of relationship with the patient and family is a barrier to the conversation for perioperative health care providers. A decision analysis tool may aid in triggering the need for a DNAR conference. Future education on the topic of DNAR status evaluation and conversation will benefit practitioners.
Mercurio, M., Maxwell, M., Mears, B., Ross, L., & Silber, T. (2008). American Academy of Pediatrics policy statements on bioethics: Summaries and commentaries: Part 2. Pediatrics in Review, 29(3), e15-e17. doi:10.1542/pir.29-3- e15
Michelson,K. & Steinhorn, D. (2007). Pediatric end-of-life issues and palliative care. Clinical Pediatric Emergency Medicine, 8 (3), 212-219. doi:10.1016/j.cpem.2007.06.006
Stack, C., & Perring, J. (2009). Pediatric DNAR orders in the perioperative period. Pediatric Anesthesia, 19 (10), 964-971. doi:10.1111/j.1460-9592.2009.03082.x