DNR (Do Not Resuscitate) and DNI (Do Not Intubate) are currently the two most common forms of orders written to limit resuscitation in US institutions. In some locales and institutions, these orders have different names such as DNAR (Do Not Attempt Resuscitation) or DNACPR (Do Not Attempt Cardiopulmonary Resuscitation). One more recent nomenclature for such orders is AND (Allow Natural Death). As the nomenclature “DNR” is probably the most uniformly recognized, it will be used throughout this chapter when referring to the ethical conflicts surrounding all such orders.

Before considering the above case regarding perioperative DNR orders, it is helpful to consider briefly the history of cardiopulmonary resuscitation and the institution of DNR orders in general.

Cardiac arrest is the final common occurrence of all natural death, absent intensive interventions such as mechanical ventilation and cardiac assist devices. Prior to the middle of the twentieth century, there were few invasive technologies available for artificially sustaining life, and there were no commonly available methods of reversing cardiac arrest. The period from the 1950s to the 1970s witnessed a large increase in the number and intensity of treatments that could stave off physiologic demise at the end of life. Furthermore, in the post-World War II period, endotracheal intubation and positive pressure ventilation became much more common during surgery with the discovery of the medical uses of curare and other nondepolarizing muscle relaxants [1]. Yet, some patients ventilated during surgery could not successfully undergo tracheal extubation at the end of the surgical case. The need to provide care for these postoperative patients and other seriously ill patients requiring ventilator support lead to the development of recovery rooms and intensive care units (ICUs). In fact, Bjorn Ibsen, an anesthesiologist, opened what was most likely the first ICU in Copenhagen, Denmark in 1953 [2].

The development of improved methods of resuscitation began in the late 1950s. Safer and colleagues demonstrated the superiority of mouth-to-mouth ventilation over back pressure/arm lift or chest pressure methods of ventilation [3]. Furthermore, Gurvich, Kouwenhoven, and Zoll all contributed significantly to proving that electrical countershocks could restart a fibrillating heart [4]. One of Kouwenhoven’s students, Knickerbocker made the serendipitous discovery that pressure on the chest produced an arterial waveform [5]. Closed chest massage was subsequently combined with ventilation to resuscitate pulseless patients in the operating room [6]. Cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) were first used primarily in the operating room and recovery areas, but soon spread throughout the hospital. In a country that had conquered polio and was sending men to the moon, anything seemed possible. The ability to prolong life was assumed to be a good thing. So, CPR training soon expanded to include the general public and paramedics who provided prehospital care.

By the early 1970s, the practice of resuscitation was universal and most always provided when the heart stopped. Even if a patient’s family expressed their wish not to have their loved one resuscitated, physicians and hospitals felt that they might become liable for performing “passive euthanasia” if they did not attempt resuscitation. Patients and their families came to feel, at times, trapped by the very measures designed to help them. Western medical practice and law had evolved to require informed consent for medical interventions, yet what patients and their families now wanted was informed refusal.

Since the 1970s, there has been a trend of increasing patient autonomy in the medical arena. In 1976, the New Jersey Supreme Court decided that life-sustaining ventilation could be removed from Karen Quinlan who was in a persistent vegetative state (PVS). The US Supreme Court decided a similar case in 1990 when Nancy Cruzan’s guardian successfully argued that her feeding tube should be removed after several years of being in a PVS [7]. Subsequently, the US Congress passed the Patient Self-Determination Act that required all hospitals, nursing homes, and surgicenters to determine on admission whether patients had signed advance directives regarding their preferences for future care, should patients become unable to communicate their preferences at that time. All patients who did not have directives were to be offered education on advance directives. Although advance directives may be far from being perfectly utilized or followed, patients and their surrogates, for the most part, have been afforded the opportunity to refuse care (including resuscitation) that was not felt to be consistent with their goals. The current standard within US hospitals is that CPR is routinely provided unless patients or their surrogates have consented to a written DNR order.

Although DNR orders have been a mainstay in American institutions for decades, the one area of the hospital that has resisted embracing these orders is the surgical arena. The surgical arena includes both the operating rooms and the surgical ICUs. For many years, health care professionals practicing medicine in the surgical arena have assumed that if patients presented to an acute care area then all DNR orders were to be automatically suspended. Surgeons have either assumed that patients wanted everything done to save them or had conversations with patients preoperatively in which the surgeons believed they had obtained implicit buy-in from the patient to the operation and any measures the surgeon felt necessary to perform postoperatively [8, 9]. Anesthesiologists have also been slow to embrace the possibility of a valid DNR order in the perioperative period. In one study done in 1993, 60% of anesthesiologists surveyed assumed that DNR orders would be automatically suspended when a patient came to the operating room [10]. The American Society of Anesthesiologists (ASA) issued guidelines in 1993 stating that when patients presenting for surgery had existing DNR orders there should be “required reconsideration” of such orders. Subsequently in the 1990s, the American College of Surgeons issued guidelines regarding DNR orders similar to the ASA’s guidelines [11]. A more recent study of patient and doctor attitudes suggests that thinking has evolved, as 38% of surgeons and only 18% of anesthesiologists believed that DNR orders should be automatically suspended when patients come to the operating room [12].

The process of deciding to provide CPR to patients or to withhold CPR and other resuscitation efforts from patients is not the same around the world. In the United States, unless there is a specific order approved by patients or their surrogates not to perform resuscitation, it is almost exclusively expected that patients in cardiac arrest will receive resuscitative measures. This is certainly not the case in most other countries around the world.

In the United Kingdom (UK), the General Medical Council (GMC) licenses and regulates all physicians. The GMC publishes a guidance for physicians, including “Treatment and care towards the end of life: good practice in decision making” [13]. The portion of the guidance that addresses resuscitation decisions for patients without decision-making capacity begins in a way familiar to a US audience, stating “If a patient lacks capacity to make a decision about future CPR, you should consult any legal proxy who has authority to make the decision for the patient. If there is no legal proxy with relevant authority, you must discuss the issue with those close to the patient and with the healthcare team” [13]. The document further prescribes how a physician should proceed if a patient’s proxy disagrees with the physician’s judgment, stating “If the legal proxy requests that CPR with a small chance of success is attempted in the future, in spite of the burdens and risks, or they are sure that this is what the patient wanted, and it is your considered judgement that CPR would not be clinically appropriate and not of overall benefit for the patient, you should explore the reasons for the proxy’s request” [13]. However, it quickly becomes apparent that the ultimate decision on whether or not to attempt CPR rests with the medical practitioner and not the patient or their proxy. “If after further discussion you still consider that attempting CPR would not be of overall benefit for the patient, you are not obliged to offer to attempt CPR in the circumstances envisaged. You should explain your reasons and any other options that may be available to the legal proxy, including their right to seek a second opinion” [13]. Resuscitation is viewed alongside all other treatments as something that may or may NOT be beneficial and medically indicated for a particular patient. Similar to other medical treatments, resuscitation decisions are viewed primarily as medical decisions to be made by physicians. Thus, it is not surprising that perioperative DNR orders in the UK were formerly routinely suspended, just as they were in the US for similar reasons as described previously. Legal decisions and common practice over the last several years have granted greater autonomy to patients refusing interventions in the UK, and thus there are a greater number of surgeries being performed with some form of a DNR order in place [14].

Across the rest of Europe, the involvement of patients and their surrogates in end- of-life decisions and resuscitation varies somewhat from country to country. All available evidence points to a common denominator of physicians making the final decision to resuscitate patients. However, patient autonomy is increasing on the continent, as it is elsewhere. In Austria, a 2006 law created a formal process for advance directives for the first time. If notarized, these forms and the patient’s preferences are binding on physicians; however, “Patients document their personal views regarding extension of treatment, e.g. mechanical ventilation, resuscitation or nutrition and they can express their wishes, e.g. concerning pain therapy but only in accordance with best clinical practice (emphasis added)” [15]. In France, there has been a shift towards sharing end-of-life decisions by having physicians consult with patients and family members; yet, all resuscitation decisions are made by physicians [16].

In Asia, there is a high degree of paternalism embedded in Asian medical practice. In Japan, if physicians believe that CPR is unjustified and futile, physicians are not even required to inform their patients that they have entered a DNR order [16]. In Hong Kong, many physicians routinely ask patients to suspend their DNR orders during surgery, and patients are expected to comply with the physician’s request. There are no specific rules regarding CPR, either in or out of the operating theater, as again all aspects of resuscitation are considered medical decisions. That being said, the Hospital Authority tells physicians that it is desirable to involve patients and family members in DNR decisions, and operations under a DNR order have occurred [17].

The majority of Middle Eastern countries are Muslim. Islamic law allows DNR orders for those who are terminally ill and allows unilateral decisions by three physicians to enter such an order without patient or family involvement. One survey showed that only about 66% of Muslim physicians were aware that a DNR order was allowed in Islam [18]. However, in Israel, a largely Jewish population (although it is composed of a sizable minority of “secular Jews”) follows traditional Jewish practices when nearing end of life. Traditional Jewish law considers dying a natural progression from life to death [16]. Unless a person is one who is considered to be very close to death (a gosess), Jewish law prescribes that all measures should be taken to preserve life, including CPR [19]. Thus, in the Middle East, there appears to be a variation in practice concerning DNR orders.