The Presence of a Do-Not-Resuscitate Order (DNR) order can pose moral and ethical dilemmas for both the perioperative patient and the CRNA. Surgical intervention requiring an anesthetic may be medically indicated for a patient with a DNR order. The Patient Self Determination Act and the principle of patient autonomy establish the ethical right of a patient to make decisions about their medical care. Strict adherence to patient directives in support of their right to choose medical care can ignore the principle of professional autonomy and the integrity of the CRNA. CRNAs have obligations under the principles of beneficence and non-maleficence which may conflict with the autonomous decisions of their patients.
The rationale for DNR orders is to acknowledge the patient's right to choose to die with dignity without prolonging his/her life by artificial means. In recognition of the fact that therapeutic interventions germane to the practice of anesthesia i.e., endotracheal intubation, controlled ventilation, administration of fluids and vasoactive drugs, might be deemed inappropriate interventions for a patient with a DNR order, the policy for a patient with a DNR order should be one of, "required reconsideration" (Cohen & Cohen). The DNR order should be discussed with the patient or, in the case of a patient no longer capable of independent decision making, his or her proxy. The conversation should be documented in the patient's chart. Documentation should include a summary of the agreed plan of care, the parties involved in the discussion and the circumstances under which the DNR order is to be restored, if suspended during the perioperative period. If the decision is made to retain the DNR order during surgery, the specific therapeutic anesthetic interventions that are to be withheld must be understood and documented in the patient's chart.
Background: Since December 1, 1992 hospitals that receive Medicare or Medicaid funds must advise patients of their right to execute advanced directives. In addition, hospitals seeking accreditation from the Joint Commission of Accreditation of Health Care Organizations are required to have DNR policies. At one time it was deemed inappropriate for a patient with a DNR order to undergo surgery, today more and more patients present for palliative surgical procedures with DNR orders.
In many institutions the standard policy for patients undergoing surgical intervention and anesthesia in the OR is to automatically suspend the DNR order. Automatic suspension of the DNR order during the perioperative period fails to comply with the principle of patient autonomy and the patient's ethical right to make decisions about their medical care. In addition, if the patient or proxy is not informed of the automatic DNR suspension during the process of informed consent to surgery and anesthesia, then the validity of the informed consent is in question and the potential for a "wrongful life" suit is raised.
If the DNR order is retained during the perioperative period, serious moral and ethical issues are raised on behalf of the CRNA and other members of the surgical team. Automatic retention of the DNR order during perioperative anesthesia care may negate the professional autonomy of the healthcare provider to act in a manner that is consistent with their moral, ethical and professional values. The principle of beneficence requires healthcare providers to "do good" and the principle of non-maleficence requires them to "do no harm"'. These principles are violated when a patient's physiological response to the anesthetic requires therapeutic intervention by the CRNA that can not be rendered because of a DNR order.
An either/or approach to the problem posed by a DNR order in the perioperative setting is ethically problematic. Adopting a policy statement that requires reconsideration of all DNR orders before patients undergo surgery and anesthesia demonstrates respect for patients rights, as well as respect for the CRNA's moral, ethical, and professional values. Required reconsideration provides all parties the opportunity to share information and clarify any misunderstandings about the goals of palliative surgical procedures and anesthesia care. Patients or their proxy may elect to suspend the DNR order once they realize that certain perioperative events require routine therapeutic anesthetic interventions that may be deemed inappropriate while a DNR order is in effect. Furthermore, if therapeutic anesthetic outcomes cannot be achieved or if the patient's condition deteriorates, the DNR order can be reinstated as agreed by all parties. The specific issues addressed during the conversation and the decisions reached must be documented in the patient's record.
If the patient or proxy decides to retain the DNR order, the CRNA and other healthcare providers should honor the request. If the CRNA is not morally or ethically willing to honor the patient's request then the CRNA should facilitate the transfer of the patient's anesthesia care to a colleague who can abide by the patient's request.
Bibliography
Reeder JM, Do-not-resuscitate order in the operating room, AORN Journal 1993,57:947-951.
Cohen CB and Cohen PJ, Do-not-resuscitate orders in the operating room, NEJM 1991, 325:1879-1882.
Martin RL, Soifer BE, Stevens WC, Ethical issues in Anesthesia: Management of the do-not-resuscitate patient, Anesth Analg, 1991, 73:221-225.
Greenwald E and Lomanto C, Do-not-resuscitate and the Anesthesiologist, New York State J of Med, 1992, 92:129-130.
Lo B, Unanswered questions about DNR orders, JAMA, 1991 265:1874-1875.
Younger SJ, Cascorbi BF, Shuck JM, DNR in the operating room, JAMA, 1991, 266:2433-2434.
Hassmiller S, Bringing the patient self-determination act into practice, Nursing Management, 1991, 22:29-32.
Walker RM, DNR in the OR, JAMA, 1991, 266:2407-2411.
Daly R and Seravalli E, Do-not-resuscitate orders during anesthesia and surgery, Anesth, 1991, 75:709-710.
Lang DA, Consent volition, and professional restraint: the patient who wants to die, Seminars in Anesthesia, 1991,10:170-174.
Franklin CM and Rothenberg DM, Do-not-resuscitate orders in the presurgical patient, J Clin Anesth, 1992, 4:181-184.
Schafer A, Implementing a DNR policy: promise and perils, Can J Anesth, 1991, 38:549-552.
Clemency MV and Thompson NJ, "Do not resuscitate" (DNR) orders and anesthesiologist: a survey, Anesth Analg, 1993, 76:394-401.
Troug RD, "Do-not-resuscitate" orders during anesthesia and surgery, Anesth, 1991, 74:606-608.
Keffer MJ and Keffer HL, Do-not-resuscitate in the operating room: moral obligations of anesthesiologists, Anesth Analg, 1992, 74:901-905.
Adopted by AANA Board of Directors June 1994
Posted April 13, 2004
Back to Practice Documents
|