Editorial: Document Patients' Wishes About Surgery at the End of Life
Key findings
- Patients with life-limiting illnesses should be given opportunities to comprehensively explore end-of-life issues
- Surgeons and physicians at Massachusetts General Hospital propose that a do-not-operate (DNO) section be added to medical and physician orders for life-sustaining treatment
- The principal purpose of a DNO would be to reduce suffering from nonbeneficial surgical interventions in patients with severe illness at the end of life
Completing a medical order for life-sustaining treatment (MOLST) and physician order for life-sustaining treatment (POLST) are concise ways to document patients' wishes based on informed decision-making. Use of these forms has been found to decrease patient anxiety and improve the family's satisfaction with the patient's end-of-life care.
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However, these forms don't clearly document the patient's wishes about operative intervention. Surgeons and physicians at Massachusetts General Hospital propose that a do-not-operate (DNO) section be added to MOLST and POLST forms, in addition to do-not-resuscitate (DNR) and do-not-intubate (DNI) orders.
The editorial is published in the Journal of Palliative Medicine by Christy E. Cauley, MD, MPH, of the Division of General & Gastrointestinal Surgery, and Motaz Qadan, MD, PhD, of the Division Surgical Oncology at Mass General, and colleagues.
Rationale for DNOs
Even in subacute and elective settings, surgery to prolong life or alleviate suffering may not always be desired, particularly when a patient's prognosis is grave. The principal purpose of a DNO would be to reduce suffering from nonbeneficial surgical interventions in patients with severe illness at the end of life.
Of course, the emergent setting is frequently the most challenging. The patient may not be lucid and family members may be unavailable or unsure about how to proceed. In addition, surgeons, patients and family members may focus only on the acute problem, losing sight of the underlying disease process and broader outlook.
A DNO order could help ensure that the patient's wishes are clearly conveyed and respected. Like DNR and DNI orders, it would be distinct from an advanced directive or living will.
Accounting for Ambivalence
The term "operate" encompasses endoscopy and laparoscopy as well as open procedures. However, this definition is no more ambivalent than the term "resuscitate" within DNRs. The potential to confuse patients is outweighed by the benefit of discussing wishes and goals for care and identifying individuals who have a clear-cut wish to avoid surgical intervention.
The editorialists recommend making provisions for ''partial'' DNO orders and allowing patients to omit, suspend or reverse a DNO order at any time.
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