The Do Not Resuscitate (DNR) order in the perioperative setting: practical considerations

Abstract

Purpose of review Addressing patients’ Do Not Resuscitate (DNR) status in the perioperative setting is important for shared patient decision-making. Although the inherently resuscitative nature of anesthesia and surgery may pose an ethical quandary for clinicians tasked with caring for the patient, anesthesiologist-led efforts need to evaluate all aspects of the DNR order and operative procedures. Recent findings Approximately 15% of patients undergoing surgical procedures have a preexisting DNR order (Margolis et al., 1995) [1]. American Society of Anesthesiologists (ASA) and the American College of Surgeons (ACS) do not support automatic reversal of the DNR order in the perioperative setting. Citing patient self-determination and autonomy, these societies advocate for a thoughtful discussion where a patient or legal designee may make an informed decision regarding resuscitation in the perioperative setting. Although studies have suggested increased perioperative mortality among patients with a preexisting DNR order, this data remains largely inconclusive. Summary Efforts must be made to address the DNR order in the perioperative setting. The fundamental tenets of medical ethics, nonmaleficence, beneficence, and patient autonomy can help to guide this oftentimes challenging discussion.

Treatment of patients with ‘do not intubate orders’

“…NIRS failure rate up to 40% is described due to patient's discomfort and refusal to continue treatment in most cases [24]. In a recent survey [25] conducted on patients without limitation of care, assisted by NIRS, it is reported that patient's experience was unpleasant due to intolerance of the interface used and the lack of relief from respiratory distress.…”

“…In this case, it is essential to review, when possible, with the patient, all the advance directives in place before proceeding with any therapeutic action, to make clear what interventions may be accepted and which refused. The delicate relationship between perioperative care and do-not-resuscitate order is the matter of intense debate and investigation in the ethical field [24]. The same cannot be said for specific advance directives, such as a DNI order, wherein the indications are not so clear and detailed.…”

Use of conditional medical orders to minimize moral, ethical, and legal risk in critical care

“…The CMO operationalizes patients' preferences in a brief form that facilitates quick decisions which are important in community settings and preoperative situations. 35 Following adequate discussion of their potential benefits and harms, additional orders can also be added for this purpose, e.g., Do-Not-Hospitalize or Do-Not Operate-Unless. This is consistent with the recommendation that a medical order should clearly outline what treatments are appropriate for a patient, and those that should be withheld.…”