“Do Not Resuscitate” Orders are not Automatically Suspended in the Operating Room
Kirk Lalwani MD, FRCA
Vincent K. Lew BA (MSII)
Cardiopulmonary resuscitation (CPR) is the only medical intervention that can be performed by a nonphysician without a physician’s order or the patient’s verbal consent. Consent to perform CPR is automatically presumed when the patient is unable to communicate his or her wish. Although CPR has the potential to reverse cardiac arrest, it may also unduly prolong life, cause unwarranted discomfort, and increase emotional distress.
Two central principles of medical ethics guide physicians in medicine: beneficence and nonmalfeasance. Though these tenets are instilled in all physicians, health care providers also have a duty to respect the wishes of the patient and his or her family. Patient autonomy reflects the right to self-governance and individuality. A provider may be forced to accept a patient’s medical decision to refuse treatment, even if it results in the patient’s death. Thus, the desire to preserve life without doing harm may conflict with the patient’s wishes, and this is often encountered in patients with a “Do Not Resuscitate” (DNR) order.
THE DNR ORDER
DNR orders were created in the 1970s for terminally ill patients in order to prevent resuscitation from cardiac arrest resulting from the primary disease or its effects. Hospitals noticed a dramatic increase in DNR orders in 1988 following the Joint Commission on Accreditation of Healthcare Organization (JCAHO) mandate that all hospitals must develop formal policies regarding DNRs.
Unfortunately, DNR orders are often poorly worded. They can be vague (“treat me aggressively unless my condition is irreversible”), overly restrictive (“no life support desired”), or out of date. Documentation frequently omits the reason for the DNR order, how it applies, when it is valid, what procedures are covered, and what was discussed. This can be a problem when patients undergoing surgery have not indicated whether the DNR order applies in the operating room (OR). Legally, when documentation is unclear or unauthenticated, life-sustaining treatment is presumed and must be administered.
DNR IN THE PERIOPERATIVE SETTING
Providers in the perioperative setting are often reluctant to adhere to DNR orders. The decision to suspend or uphold the DNR order has been the subject of much debate. There are three main issues that providers must confront with a DNR order in the OR.
First, by virtue of consenting to surgery, the patient expects to benefit either symptomatically or functionally from the procedure. Patients who undergo surgery have a reasonable expectation to survive the operation in order to obtain that benefit. The very objective of undergoing surgery would be redundant if the patient were allowed to die during the operation. Thus, the DNR order opposes the goal of surgery.
Second, the nature of anesthesia increases the chance of cardiac or respiratory arrest by producing profound disruption in normal physiologic functions such as consciousness, circulation, and breathing. Anesthesia frequently involves measures such as assisted ventilation, endotracheal intubation, and intravenous fluid resuscitation that are considered “resuscitative”; anesthesia may also induce cardiopulmonary arrest that may be readily reversible. Further, the survival rate of patients requiring CPR in the OR is very different from that of patients who have unwitnessed arrests; the difference may be attributed to the OR environment, in which patients are continuously monitored and physicians trained to administer CPR are always present. The overall recovery rate of CPR in anesthesia-related arrests is more than 90%. In contrast, cardiac arrests in patients elsewhere in the hospital have significantly lower survival rates (2% to 6% in general wards, 19% in intensive care units). Therefore, it is relevant to distinguish between arrests caused by the primary disease and those caused by anesthesia in the perioperative setting.