From the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon.
Department of Anesthesiology, Yale University, New Haven, Connecticut.
Anesth Analg. 2021 Sep 1;133(3):663-675. doi: 10.1213/ANE.0000000000005559.
No patient arrives at the hospital to undergo general anesthesia for its own sake. Anesthesiology is a symbiont specialty, with the primary mission of preventing physical and psychological pain, easing anxiety, and shepherding physiologic homeostasis so that other care may safely progress. For most elective surgeries, the patient-anesthesiologist relationship begins shortly before and ends after the immediate perioperative period. While this may tempt anesthesiologists to defer goals of care discussions to our surgical or primary care colleagues, we have both an ethical and a practical imperative to share this responsibility. Since the early 1990s, the American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA), and the Association of Perioperative Registered Nurses (AORN) have mandated a "required reconsideration" of do-not-resuscitate (DNR) orders. Key ethical considerations and guiding principles informing this "required reconsideration" have been extensively discussed in the literature and include respect for patient autonomy, beneficence, and nonmaleficence. In this article, we address how well these principles and guidelines are translated into daily clinical practice and how often anesthesiologists actually discuss goals of care or potential limitations to life-sustaining medical treatments (LSMTs) before administering anesthesia or sedation. Having done so, we review how often providers implement goal-concordant care, that is, care that reflects and adheres to the stated patient wishes. We conclude with describing several key gaps in the literature on goal-concordance of perioperative care for patients with limitations on LSMT and summarize novel strategies and promising efforts described in recent literature to improve goal-concordance of perioperative care.
没有患者会因为自身原因而选择接受全身麻醉。麻醉学是一种共生专业，其主要任务是预防身体和心理疼痛，缓解焦虑，并维持生理平衡，以便其他治疗能够安全进行。对于大多数择期手术，患者与麻醉医生的关系始于手术前的近期和术后的恢复期。尽管这可能会诱使麻醉医生将治疗目标的讨论推迟给我们的外科或初级保健同事，但我们有道德和实践的必要来共同承担这一责任。自 20 世纪 90 年代初以来，美国外科医师学会（ACS）、美国麻醉医师学会（ASA）和围手术期注册护士协会（AORN）已经要求对“不复苏”（DNR）医嘱进行“重新考虑”。文献中广泛讨论了指导这一“重新考虑”的关键伦理考虑因素和指导原则，包括尊重患者自主权、善行和不伤害。在本文中，我们探讨了这些原则和准则在日常临床实践中的转化程度，以及麻醉医生在给予麻醉或镇静前实际讨论治疗目标或潜在生命支持治疗（LSMT）限制的频率。在这样做之后，我们回顾了提供者实施与目标一致的护理的频率，即反映和遵守患者意愿的护理。我们以描述 LSMT 限制患者围手术期护理目标一致性文献中的几个关键差距结束，并总结了最近文献中描述的改善围手术期护理目标一致性的几种新策略和有前途的努力。
