Division of Cardiology, University of Washington, Seattle, Washington, USA.
Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
J Am Geriatr Soc. 2022 Dec;70(12):3378-3389. doi: 10.1111/jgs.17980. Epub 2022 Aug 9.
Little is known about policies and practices for patients undergoing Transcatheter Aortic Valve Replacement (TAVR) who have a documented preference for Do Not Resuscitate (DNR) status at time of referral. We investigated how practices across TAVR programs align with goals of care for patients presenting with DNR status.
Between June and September 2019, we conducted semi-structured interviews with TAVR coordinators from 52/73 invited programs (71%) in Washington and California (TAVR volume > 100/year:34%; 50-99:36%; 1-50:30%); 2 programs reported no TAVR in 2018. TAVR coordinators described peri-procedural code status policies and practices and how they accommodate patients' goals of care. We used data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, stratified by programs' DNR practice, to examine differences in program size, patient characteristics and risk status, and outcomes.
Nearly all TAVR programs (48/50: 96%) addressed peri-procedural code status, yet only 26% had established policies. Temporarily rescinding DNR status until after TAVR was the norm (78%), yet time frames for reinstatement varied (38% <48 h post-TAVR; 44% 48 h-to-discharge; 18% >30 days post-discharge). For patients with fluctuating code status, no routine practices for discharge documentation were well-described. No clinically substantial differences by code status practice were noted in Society of Thoracic Surgeons Predicted Risk of Mortality risk score, peri-procedural or in-hospital cardiac arrest, or hospice disposition. Six programs maintaining DNR status recognized TAVR as a palliative procedure. Among programs categorically reversing patients' DNR status, the rationale for differing lengths of time to reinstatement reflect divergent views on accountability and reporting requirements.
Marked heterogeneity exists in management of peri-procedural code status across TAVR programs, including timeframe for reestablishing DNR status post-procedure. These findings call for standardization of DNR decisions at specific care points (before/during/after TAVR) to ensure consistent alignment with patients' health-related goals and values.
对于在转诊时已记录有“不复苏”（Do Not Resuscitate，DNR）意愿的行经导管主动脉瓣置换术（Transcatheter Aortic Valve Replacement，TAVR）患者，我们对其相关政策和实践知之甚少。本研究旨在调查 TAVR 项目的实践与 DNR 状态患者的治疗目标之间的一致性。
2019 年 6 月至 9 月，我们对加利福尼亚州和华盛顿州 52/73 个（71%）受邀 TAVR 项目的 TAVR 协调员进行了半结构化访谈；其中 TAVR 年手术量超过 100 例的项目占 34%，50-99 例的占 36%，1-50 例的占 30%；2 个项目在 2018 年未进行 TAVR。TAVR 协调员描述了围手术期代码状态的政策和实践，以及他们如何适应患者的治疗目标。我们使用了美国胸外科医师学会/美国心脏病学会经导管瓣膜治疗登记处的数据，按项目的 DNR 实践进行分层，以检查不同项目规模、患者特征和风险状况以及结果之间的差异。
几乎所有 TAVR 项目（48/50：96%）都涉及围手术期代码状态，但只有 26%的项目制定了政策。在 TAVR 之后暂时撤销 DNR 状态是常规做法（78%），但恢复的时间框架不同（38%<48 小时；44%在 48 小时至出院期间；18%>30 天出院后）。对于代码状态波动的患者，没有常规的出院记录做法。在胸外科医师学会预测死亡率风险评分、围手术期或院内心脏骤停或临终关怀处置方面，按代码状态实践划分，没有明显的临床差异。有 6 个项目将 DNR 状态维持在 TAVR 作为姑息治疗的状态。在明确反转患者 DNR 状态的项目中，恢复时间长短的不同反映了对问责制和报告要求的不同看法。
在 TAVR 项目中，围手术期代码状态的管理存在明显的异质性，包括术后重新建立 DNR 状态的时间框架。这些发现呼吁在特定的治疗点（TAVR 之前/期间/之后）标准化 DNR 决策，以确保与患者的健康相关目标和价值观保持一致。
