July 10, 2023
However, several experts in this area are urging surgeons to explore and document a patient’s wishes before the operation to help avoid disagreements during and after the procedure.
In 2013, the ACS issued a revised Statement on the Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room (the original statement was issued in 1994) that focused on patients who accept a surgeon’s recommendation to have surgery and already have a DNAR in place. The statement notes that the best approach for these patients is a policy of “required reconsideration” of the existing DNAR orders.1
In addition, the American Medical Association Code of Ethics states that the ethical obligation to respect patient autonomy and self-determination requires that physicians respect decisions to refuse care, suggesting that physicians should address the potential need for resuscitation early in the patient’s course of care.2
“We’ve had this policy for a long time, and it’s probably not working exactly as we envisioned,” said Margaret “Gretchen” Schwarze, MD, MPP, FACS, a vascular surgeon and medical ethicist at the University of Wisconsin (UW)-Madison. UW-Madison has a policy mandating preoperative conversations about DNAR orders.
In fact, authors of a recent article in the Journal of the American College of Surgeons (JACS) described the OR as the “last bastion of resistance to acceptance of DNAR orders.”3
Why have some clinicians failed to adopt and practice the concept of required reconsideration for patients with DNARs going to the OR? The authors of the JACS article assert that there may be a number of reasons, including the inability to predict all potential scenarios in the perioperative environment, the time spent having these conversations, ambiguities associated with the decision-making process, and the need for accurate, readily accessible documentation.
Although research is scarce in this area, one study shows that nearly one-third of surgeons at the Mayo Clinic in Rochester, Minnesota, automatically suspended DNAR orders during surgery.4 One reason may be that automatically suspending the DNAR is the easiest and quickest way to handle the DNAR issue because it doesn’t involve a conversation with the patient or the surrogate.
Clinicians may choose this course when there isn’t enough time to have a conversation about the DNAR orders or if the patient doesn’t have the capacity to hold the discussion, according to Preeti R. John, MD, MPH, FACS, FCCM, HEC-C, a palliative care surgeon, intensivist and healthcare ethics consultant with the VA Maryland Health Care System in Baltimore, and lead author of the JACS article.
Dr. Schwarze added that not suspending the DNAR in the OR often goes against the grain of clinicians.
“Many surgeons feel that the whole point of surgery is for the patient to survive the operation,” she said. “So why wouldn’t we want to do everything in our power to allow the patient to survive—especially if we did something that put them in cardiac arrest that we could easily reverse in the operating room?”
This urge to suspend the DNAR order in the OR to protect the life of the patient is compounded when the clinicians’ actions—whether related to the anesthesia, the procedure, or a medical error—cause the patient to deteriorate or arrest, especially when they are in a position to immediately attempt to correct and reverse this decline.
Automatic, unilateral suspension of DNAR orders in the OR is neither best practice nor ethically justified for elective surgery because it does not respect the patient’s autonomy or the right to be truly informed about the choices they have with regard to resuscitation, Dr. John said.
Even if resuscitation may appear to have a good chance of success, this does not justify automatic suspension of DNAR orders because those efforts could cause the type of harm the patient wanted to avoid when he or she requested the order.
On the other hand, the patient needs to understand that while the DNAR order means “do not try to restart the heart when the heart stops functioning,” it does not mean “do not treat clinical deterioration,” she explained.
“Most surgeons know that, for some people, the best way to help them is not to try to prolong their life, but to make sure they’re not suffering,” Dr. Schwarze said. “That’s part of our job as much as it is to prolong life and prevent disability: prevent suffering for patients who are dying or have very serious life-limiting illness.”
Informed consent is based on the ethical principles of patient autonomy and the right to self-determination. Patients are likely to consent to surgery to improve their clinical condition or quality of life.
Normally, informed consent involves standardized, straightforward paperwork that may be modified based on the individual patient, said Linda G. Phillips, MD, FACS, a plastic and reconstructive surgeon at The University of Texas Medical Branch in Galveston, and Chair of the ACS Ethics Committee.
But for patients with DNAR orders, clinicians need to address the ambiguities associated with treatment decisions if they are to respect the patient’s autonomy and inform their consent.
“Patients don’t necessarily want to have a full court resuscitation because they’re concerned that they’ll be kept alive in a comatose state or on a ventilator,” Dr. Phillips said. “But they would still be very interested in procedures that could give them less pain, make them more comfortable, and make the time they have more enjoyable for them and those who love them.”
On occasion, for an emergency case, when there is insufficient time to have a detailed conversation and the patient’s life depends on getting to the OR as rapidly as possible, it may be necessary to do the procedure without obtaining consent.
Also, if the patient does not have decision-making capacity (e.g., because they have lost cognitive function due to dementia) and a surrogate is not available, unilateral suspension of an existing DNAR order prior to emergency surgery may be the most feasible and appropriate option.
But even in cases of emergency when the patient or surrogate is unavailable for a discussion, the decision is not a simple one, said Dr. John. For example, if there are unforeseen complications and the patient depends on life-sustaining treatments (LSTs) postprocedure, how long does the surgeon temporarily rescind the DNAR order?
Procedure-Directed Levels of Care
Level I (required routine administration of anesthesia)
Level II (required during deterioration)
Level III (excluded if DNAR order is retained)
E-CPR using ECMO circuit
At a minimum, surgeons should clarify what the DNAR order means to the patient. The DNAR order may be an indication that a patient does not want heroic measures, to stay on life support for a prolonged period, or to be in a persistent vegetative state.
“I really love this notion of required reconsideration because it doesn’t tell you what to do,” Dr. Schwarze said. “It lets you make sure everybody is on the same page before you move forward.”
The DNAR does not imply that clinical deterioration should not be treated. For example, resuscitation during hemodynamic deterioration is different from resuscitation after cardiac arrest. For many patients, the issue isn’t about resuscitation efforts, but about the risk of functional and cognitive deficits and the potential need for additional LSTs due to cardiac arrest, Dr. Schwarze said.
Clinicians should consider having both a goal-directed discussion (clarifying patient wishes and values) and a procedure-directed discussion, Dr. John said. When discussing procedures, using a levels-of-care approach that groups LSTs into categories may simplify the explanation about which LSTs are used only during an arrest (see Table).
Ultimately, patients with a DNAR order have three options before surgery:
But without a required reconsidered discussion, the clinician may not know what the patient means or intends in choosing one of these options.
Both the surgeon and anesthesiologist have a responsibility to disclose potential complications resulting from therapeutic interventions or error.
If the complication is reversible, would the patient wish to have resuscitation attempted? An array of scenarios should be discussed with the patient and family/caregivers before surgery to clarify when a DNAR order should or should not be suspended.
These clinicians also need to explain to the patient the difficulty in predicting intraoperative complications and postoperative outcomes.
Clinicians need to discuss the patient’s goals for the procedure and their longer-term, quality-of-life goals. What is the patient’s definition of a successful resuscitation? Should lifesaving therapies such as postoperative ventilator support be used and, if so, for how long? (see Figure 1)
Ultimately, surgeons and anesthesiologists should come away from the conversation with a good understanding of the nuances around the patient’s short- and-long-term goals.
“The conversation is a way to document what they’re not okay with, such as loss of cognitive function or living on a ventilator,” Dr. Schwarze said. “What kinds of burdensome treatments are they afraid of?”
Dr. Phillips added that “these kinds of discussions have to be individualized based on what their medical condition is.”
Conducting a required reconsideration conversation is challenging and time-consuming, which is why many surgeons avoid having the discussion even though they agree that it’s important.
Dr. Schwarze co-authored a research study that showed, before taking a patient in for an operation, surgeons tend to avoid having—much less documenting—advance care planning discussions that include addressing postoperative life-sustaining treatments.5 Avoiding these conversations may result in the surgeon’s inability to understand the patient’s wishes during surgery and postoperatively as well.
“We lose access sometimes to our ability to know what their preferences are, because they can’t speak to us after surgery,” Dr. Schwarze said. “We really need to figure out before surgery what kind of burdens they will tolerate.”
The choices presented should be nuanced and tailored to the individual patient, not “all or none.” For example, Dr. Schwarze said patients should not be presented with a checklist of LSTs; it is inconsistent care, and it may end up in unrealistic scenarios, such as patients demanding CPR but refusing intubation.
Likewise, presenting the patient with a checklist describing quality-of-life issues may not be practical because there are so many complicated potential scenarios for which the outcomes are difficult to accurately forecast.
“It’s hard to be absolutist in your approach,” Dr. Phillips said. “It pretty much has to be tailored to the patient, the situation, and their family.”
For patients with progressive, incurable disease, including those in hospice, palliative procedures can address symptoms and improve quality of life. For these situations, it’s especially important for the surgeon and anesthesiologist to clarify the overriding goals.
“If it’s something that is palliative and we’re doing it in such a way that it’s going to leave them permanently transformed or disfigured even, I certainly would want the ethicist present for that,” Dr. Phillips added.
Palliative procedures are further complicated by the fact that if the patient dies within 30 days after a procedure it will increase the surgeon’s 30-day mortality rate. This is a disincentive for surgeons who do not want a 30-day mortality outcome on their publicly reported records. As a result, some patients in great pain may have trouble finding a surgeon to relieve their symptoms.
“With palliative procedures, improving the quality of life is the goal,” Dr. John said.
Dr. Schwarze added that using a more sophisticated and nuanced approach may be necessary to better align the goals of surgery with measured outcomes.6
A required reconsideration discussion about whether or not to modify the DNAR order should be multidisciplinary and should occur before the day of surgery; the day of the procedure can be stressful for the patient or surrogate, who may already be overloaded with information.
Ideally, the attending surgeon and the anesthesiologist, should attend these patient discussions, as should patient surrogates or immediate family members.
The anesthesiologist should be included because putting the patient in a “suspended state” and getting them out again is a significant risk, Dr. Phillips said. General anesthesia may cause problems for the patient by suppressing the patient’s respiratory drive and consciousness and changing the patient’s hemodynamics.
The hospital ethicist should be included, especially if there are family members with opposing viewpoints regarding DNAR orders, said Dr. Phillips. Having a calm third party is helpful for what could be an emotional discussion, she said.
Unfortunately, these required reconsideration discussions often are delegated to junior members of the surgical team who may perceive asking about code status as just another box to check preoperatively, without thinking through the critical nature of this discussion.
“Especially if they have an established relationship with the patient, the surgeon needs to be there,” advised Dr. Phillips. The patient and family may not accept having a delegate assigned to the task of participating in this important conversation.
Even when the surgery is elective, many surgeons feel they do not have time to have a lengthy discussion about DNAR orders. These discussions usually last at least 30 minutes, and often can be an hour, depending on how many family members are involved, Dr. Phillips said.
But, in the end, lack of time is no excuse.
“If you have time to get good consent, you have time to talk to a patient who has a DNAR order,” Dr. Schwarze said. “This conversation should include what to do about that DNAR in the operating room, and what happens if the patient is sick after surgery and needs to be on a ventilator for a while.”
When probed with questions to clarify wishes, some patients want aggressive care while others may want to limit treatments in certain scenarios.
“Many patients will choose to suspend the DNAR order during this time because resuscitation during and immediately after a procedure has a higher chance of success,” Dr. Schwarze said. “However, some patients may choose to keep the DNAR order in effect during an operation or a procedure given the potential harm of resuscitation to their overall goals.”
Just as a Jehovah’s Witness patient can refuse a lifesaving blood transfusion during surgery, a DNAR patient may refuse resuscitation during a procedure, according to the JACS article. Neither patient intends to die on the operating table, but they accept that this may result from their refusal of certain LST measures.
In some cases, clinicians may be hesitant to treat patients who keep their DNAR orders intact during an operation.
“I have had patients who wanted to keep their DNAR order during surgery and had a hard time finding an anesthesiologist who would do the case,” Dr. Schwarze said.
Culture change is necessary to incorporate best practice recommendations into everyday clinical care and institutional policies and protocols. Since often it’s a junior resident in teaching hospitals who’s delegated to get the patient consent and clarify issues about the existing DNAR order, it is even more important to develop hospital policies and procedures for safeguarding the interests of the patients.
Prompts could be built into the electronic health record to enable documentation of these patient conversations, Dr. John said, adding that consideration should be given to linking this documentation to quality measures.
The Veterans Health Administration’s directive about LST decisions specifies that DNAR orders must not be automatically suspended prior to procedures that involve anesthesia. The VA enables documentation using a specific templated “LST note” in a standardized location within the order, according to Dr. John.
Learning how to discuss informed consent and advance directives with patients, including DNAR orders before surgery, should be taught to and practiced with surgical residents, just like other surgical skills, Dr. Schwarze said.
The demand for these types of required reconsideration conversations will only grow in the coming years.
“As the population ages,” Dr. John explained, “We’re likely to see more and more patients present for procedures with existing DNAR orders.”
Jim McCartney is a freelance writer.