[ST-19] Statement on Advance Directives by Patients: "Do
Not Resuscitate" in the Operating Room
[by the American College of Surgeons]
It is generally expected that the surgeon will accept primary
responsibility for advising patients regarding risks and benefits
when discussing a potential operation. Advance directives, including
"Do Not Resuscitate" (DNR) orders and requests, are
being used with increasing frequency and may, at times, complicate
the operative consent process. Under such circumstances, it is
even more important that the surgeon take a leadership role in
assisting the patient and surgical team through this important
aspect of surgical care.
Some patients with DNR status become candidates for surgical
procedures that may provide them with significant benefit even
though the procedure may not change the natural history of the
underlying disease. (Examples include procedures to treat intestinal
obstruction in individuals with advanced malignancy and surgical
procedures to alleviate pain.) When such patients undergo surgical
procedures and the accompanying sedation or anesthesia, they
are subjected to new and potentially correctable risks of cardiopulmonary
arrest. Furthermore, many of the therapeutic actions employed
in resuscitation (for example, intubation, mechanical ventilation,
and administration of vasoactive drugs) are also an integral
part of anesthetic management, and it is appropriate that the
patient be so informed. The DNR status of such patients during
the operative procedure and during the immediate postoperative
period may need to be modified prior to operation.
Policies that lead either to the automatic enforcement of
all DNR orders and requests or to disregarding or automatic cancellation
of such orders and requests during the operation and recovery
period may not sufficiently address a patient's right to self-determination.
An institutional policy of automatic cancellation of the DNR
status in cases where a surgical procedure is to be carried out
removes the patient from appropriate participation in decision
making. Automatic enforcement without discussion and clarification
may lead to inappropriate perioperative and anesthetic management.
The best approach is a policy of "required reconsideration"
of previous advance directives. The patient and the physicians
who will be responsible for the patient's care should discuss
the new risks and the approach to potential life-threatening
problems during the perioperative period. The results of such
discussions should be documented in the record.
The operative and anesthetic permit should indicate that the
patient or the duly authorized patient's representative has had
the opportunity to discuss and reconsider any advance directive.
An example follows:
In preparation for your operative procedure and the immediate
postoperative period, your advance directive (such as "Do
Not Resuscitate") may need to be modified. If you currently
have such an advance directive, it should be discussed with your
surgeon and anesthesiologist prior to the operative procedure.
Once a decision is reached regarding interpretation of the
patient's advance directive, the surgeon must continue his or
her leadership role in (1) conveying the patient's advance directive
to the members of the operating room team, (2) if necessary,
helping the operating room team members understand and interpret
the patient's advance directive, and (3) where possible, finding
an alternate team member to replace an individual who has an
ethical conflict with the patient's advance directive.
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Bibliography
- Joint Commission on Accreditation of Healthcare Organizations:
Manual of the Joint Commission on Accreditation of Health
Care Organizations. Patient Rights Chapter. Chicago, IL:
JCAHO, 1994.
- Reeder J M: Do Not Resuscitate orders in the operating room.
AORN J, 57:947-051, April 1993.
- Troug RD: Do Not Resuscitate orders during anesthesia and
surgery. Anesthesiology, 74:606-608, March 1991.
- Regnier S J: Symposium underscores value of OR teamwork:
Report on Eighth Symposium on the Operating Room Environment,
May 3-5, 1993, Baltimore, MD. Bull Am Coll Surg, 78(7):73-81.
- American Society of Anesthesiologists: Ethical guidelines
for the anesthesia care of patients with Do Not Resuscitate orders
or other directives that limit treatment. House of Delegates,
American Society of Anesthesiologists, Park Ridge, IL, October
13, 1993.
Statements
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Reprinted from Bulletin of the American College
of Surgeons
Vol. 79 No. 9, Page 29, September 1994
