A 64-year-old woman presented for right hip replacement. She had a history of myasthenia gravis, unresponsive to therapy. When healthy, her exercise tolerance was equal to 4 METS; however, exacerbations precipitated by minor illness confined her to bed. She has refused cardiopulmonary resuscitation (“do not resuscitate” [DNR]) or intubation (“do not intubate” [DNI]) in the event of an emergency. You informed the patient you would like to discuss her DNR/DNI orders, and the patient did not understand why because the procedure was going to be done under spinal anesthesia.
Does the american society of anesthesiologists have guidelines for do not resuscitate orders or other directives that limit treatment?
The (ASA) last affirmed ethical guidelines for the anesthesia care of patients with DNR orders or other directives that limit treatment in 2008. The ASA guidelines apply to competent patients and incompetent patients who previously expressed their preferences. Before the early 1990s, when the guidelines were first written, it was assumed that DNR orders were automatically revoked while a patient was in the operating room because anesthesia and surgery were deemed to be a temporary altered state. Also, many procedures and drugs used routinely in the operating room can be considered as resuscitative. Guidelines recommending automatic suspension violate patients’ rights of self-determination in a responsible and ethical manner. Instead, communication between the physician and the patient is an essential element of the preoperative preparation to determine goals of care.
What options regarding resuscitation efforts in the operating room should be discussed with the patient or the patient’s surrogate before administration of anesthesia?
Because administration of anesthesia and surgery involve procedures and practices that overlap with resuscitation, the anesthesiologist can provide the following alternatives to full dismissal of DNR status:
Full attempt at resuscitation: Because the period of time under anesthesia and in the immediate postoperative period is an alternate state, the patient or surrogate may request full suspension of existing directives during this time. All resuscitative efforts can then be brought to bear.
Limited attempt at resuscitation defined with regard to specific procedures: The patient or surrogate may choose to refuse specific resuscitation procedures. The anesthesiologist discusses with the patient or surrogate the procedures that may need to be performed, highlighting which procedures are essential for the success of anesthesia and surgery versus the procedures that are not essential and can be refused. Procedures that are frequently discussed include chest compressions, defibrillation, tracheal intubation, administration of resuscitative medications, use of supplemental oxygen, placement of central lines, invasive monitoring, and use of bag and mask ventilation. The procedure-related DNR approach requires anticipation of the most likely problems that may occur and limits the physician when an unexpected situation arises. However, this approach does make it easier to implement DNR orders successfully when multiple caregivers are involved. There is a concern that when faced with limited treatment options, the anesthesiologist may provide a “light” anesthetic to decrease the likelihood of needing any form of resuscitation, ultimately resulting in inadequate anesthesia.
Limited attempt at resuscitation defined with regard to the patient’s goals and values: The patient or surrogate may allow the anesthesiologist to make decisions regarding acceptable treatments based on the patient’s goals and values rather than on individual procedures. Some patients may find certain treatments acceptable if the clinical event is temporary and quickly reversible but would want treatment withheld if the condition is or becomes irreversible or would result in permanent damage. Patients are often less concerned with the technical details of resuscitation and more concerned with issues such as the potential for pain and long-term outcomes of resuscitation. This approach allows for treatment of unexpected cardiac or respiratory events as long as that treatment complies with the patient’s care goals. However, some anesthesiologists may be uncomfortable with the goal-directed DNR approach. They may have legal and ethical concerns regarding their decisions based on their best judgment during the time of the critical event. This method works only if the team caring for the patient throughout the case maintains consistency. There is too great a risk of misinterpretation of patient’s goals if they are passed on from one anesthesiologist to another. Ideally, the individuals taking care of the patient should have first-hand knowledge of the patient and were involved in the discussion of the patient’s goals. Most physicians prefer the adaptability and flexibility of this approach, but it does require a high degree of trust between the patient and physicians, which is not always possible. Documentation of the goal-directed DNR approach should include a narrative that summarizes the discussions that occurred between the patient and physicians.