Patient’s rights to self-determination include the right to refuse life-saving procedures, should they become incapacitated. Do Not Resuscitate (DNR) order are directives that limit treatment if the person should need it at any time. DNR orders pose a particular problem in the field of anesthesia. Anesthesia procedures sometimes require procedures that would be considered “resuscitation” under other circumstances (ASA House of Delegates, 2001). DNR orders and other advance directives need to be reviewed with the patient and their designated surrogate prior to any surgical procedure (ASA House of Delegates, 2001). There several key considerations to address concerning DNR orders prior to any surgical procedure.
One method to address these issues is to temporarily suspend the orders prior to surgery. However, there are concerns that this option may not fully address the rights of the patients (ASA House of Delegates, 2001). DNR orders are typically meant to cover abnormal circumstances, such as an automobile accident. Some patients with terminal illnesses may also have advance directives in place. Those that are having surgical procedures are doing to so either improve their quality of life, or in some cases, to prolong life. These two concepts are in direct conflict with the principle behind an advance directive.
Policies that automatically suspend DNR orders for surgery is based on this conflict. It is assumed that the patient’s most recent decision to have surgery overrides their prior decision to put advance directives in place. In the case where the patient has surgery, undergoes a routine resuscitative procedure and then fully recovers, this I is the correct choice. However, in the case where the patient undergoes the procedure and something goes wrong, leaving them in a vegetative state, then the issue becomes more complicate because this was the exact situation that the DNR orders were meant to prevent. With any procedure involving anesthesia this is always a possibility.
The ASA recognizes three potential solutions to DNR orders and surgical procedures. All of these should be discussed with the patient and their surrogate prior to the procedure, and should be on file. The first option is full suspension of existing directives. The second is limited attempts at resuscitation regarding certain procedures. In this case, the anesthesiologist must clearly define for the patient and their surrogate which procedures are a necessary and routine part of the procedure and which ones may be refused (ASA House of Delegates, 2001). Another option is to allow the patient to accept resuscitation for conditions that are quickly and easily reversible, but not for those where permanent dependence on life support is necessary (ASA House of Delegates, 2001). Separating out resuscitation that is a part of the procedure from that which is not a “routine” part of the procedure can be difficult for anesthesiologists (Kelly, 2014).
In some cases, the anesthesiologist may be tempted to administer less than optimal anesthesia in order to keep the patient stable (Kelly, 2014). In some cases, the anesthesiologist may not be able to honor the patient’s wishes due to their own personal convictions. In this case the anesthesiologist has the right to transfer services to another person who feels more comfortable with the patient’s decisions (AANA, 2010). The same goes for a physician who feels that they could not bring themselves to honor the wishes of a patient who wishes them to allow them to die, rather than resuscitate them. This issue not only involves the morals and beliefs of the patients it involves the beliefs of the physician and anesthesiologists as well.
The ethics of palliative care and DNR orders is tricky enough when it comes to adults, but it becomes even more complex when one is dealing with a pediatric patient. The most important factor to consider in this case is the difference between “goal directed” policies and “procedure-directed” approaches (Fallat & Deshpande, 2013). Goal directed policies involve the ultimate goals of the patient. Procedure-directed policies only involve the specific procedure that is being considered. One of the key issues in patient care is to make certain it is clear whether they are goal-directed or whether they only apply to the current procedure.
The patient has the ultimate right to make decisions regarding their care and under the law, the physician must comply (Ball, 2009). Documentation is essential when a DNR is s suspended for surgery. It must be clear when the DNR order will be reinstated (National Center for Ethics in Healthcare, 2005). When the idea of DNR orders first began in the 1970s, they were written to be general in nature. As the field of medicine and advanced life support progressed, the need arose to consider the situation in which they should be applied. Current state of though on DNR orders is that they must be clear on the location, timing, and circumstances surrounding the order (Ball, 2009). General DNR orders do not meet this criteria. The problem is that many DNR orders were written when the patient faced a specific healthcare crisis.
For the anesthesiologist, discussing DNR wishes and orders prior to a procedure is essential. Even if the patient currently has no DNR orders in place, the topic should come up in the initial consult. The patient must understand the various procedures that may be used as a part of normal surgical procedures, and which ones would be used if an unexpected event should occur. The key to cover all foreseeable possibilities and to get specific instructions from the patient to cover all circumstances. A clear understanding by all parties is the best practice regarding DNR orders in the operating theater. Documentation of conversations regarding DNR orders is the key to avoiding conflict both during and after the procedure. It is essential to make certain that all staff member have a clear understanding of the patient’s wishes, including when the scope of the DNR order ends.
