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March 2001
Volume 65 |
Number 3
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| Informed
Consent for the Patient With an Existing DNR Order |
David B. Waisel, M.D.
Robert D. Truog, M.D.
Committee on Ethics
In 1993, ASA published Ethical Guidelines
for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders
or Other Directives That Limit Treatment. This statement endorsed
patients’ rights to refuse resuscitation in the operating room
and suggested that standing do-not-resuscitate (DNR) orders be
re-evaluated for the perioperative period instead of being automatically
revoked. The American College of Surgeons published a similar
statement in 1994.
While it is clear that re-evaluating orders
for the perioperative period is ethically unassailable, it is
equally clear that clinical implementation of re-evaluation is
problematic. To that end, the Committee on Ethics developed the
Informed Consent for Anesthesia Care in the Patient With an Existing
Do-Not-Resuscitate Order form to facilitate discussion and documentation
of perioperative DNR orders. The form consists of the four options
discussed below.
OPTION 1. FULL RESUSCITATION
I, _________________, desire that full resuscitative measures
be employed during my anesthesia and in the postanesthesia care
unit, regardless of the situation.
Most articles discuss methods for patients to refuse therapy
in the perioperative period because historically the status quo
has been to insist upon full resuscitation. This does not mean,
however, that it is inappropriate for a patient to revoke the
DNR order. Indeed, there are a number of reasons why a patient
may prefer this option. A clear reference, such as revocation,
avoids the question of determining what is resuscitation and reassures
patients that no effort will be spared in performing resuscitation.
In addition, outcomes from cardiopulmonary resuscitation (CPR)
performed in the operating room are far superior to outcomes from
CPR performed outside the operating room. Revocation works well
for patients who will accept any burden in exchange for any possible
benefit of therapy.
OPTION 2. LIMITED RESUSCITATION: PROCEDURE-DIRECTED
During my anesthesia and in the postoperative care unit, I,
________________, refuse the following procedures:
Some patients may prefer the security of being able to define
precisely what interventions are permitted. Anesthesiologists
advise their patients based on the benefit and burden of the intervention
as well as the likelihood of that intervention allowing the patient
to achieve desired goals. Interventions on such lists include
tracheal intubation or other airway management, postoperative
ventilation, chest compressions, defibrillation, vasoactive drugs
and invasive monitoring. Patients should be informed that inconsistent
or incompatible requests cannot be honored. The inconsistent nature
of some requests, such as receiving intravenous medications but
not having an intravenous line placed, needs to be clarified to
the patient. For another similar example, consider the need for
general endotracheal intubation to relieve a bowel obstruction
in a patient receiving chronic anticoagulation therapy. In this
case, the patient needs to be informed that tracheal intubation
is mandatory for the anesthesia and surgery to occur and that
the patient can either have the surgery with the tracheal intubation
or can refuse surgery. Although the patient must have tracheal
intubation to facilitate anesthesia, the patient may still refuse
other forms of resuscitation and may opt to define circumstances
in which to have care withdrawn postoperatively.
Procedure-directed orders work well for patients who want to
unambiguously define which procedures are desired and, for that
benefit, are willing to forego the ability of perioperative caregivers
to customize the extent of resuscitation based upon clinical situations
that may be difficult to predict.
OPTION 3. LIMITED RESUSCITATION: GOAL-DIRECTED
I, _________________, desire attempts to resuscitate me during
my anesthesia and in the postanesthesia care unit only if, in
the clinical judgment of the attending anesthesiologist and surgeon,
the adverse clinical events are believed to be both temporary
and reversible.
OPTION 4. LIMITED RESUSCITATION: GOAL-DIRECTED
I, ___________________, desire attempts to resuscitate me
during my anesthesia and in the postanesthesia care unit only
if, in the clinical judgment of the attending anesthesiologist
and surgeon, such resuscitation efforts will support the following
goals and values of mine:
The form also should offer two options for goal-directed orders.
Clinical experience indicates that many patients prefer Option
3 as a standard goal-directed order, and we would recommend that
as the starting point. If, however, the phrase temporary and reversible
does not adequately describe the patient's desires, Option 4 may
be used for the patient to clarify his or her goals.
The goal-directed approach arose from the idea that since many
patients think in terms of outcomes, it is often more effective
to talk about goals rather than procedures. By taking advantage
of the operating room environment in which specific physicians
take care of a patient for a defined period of time, patients
may guide therapy by prioritizing outcomes rather than procedures.
After defining desirable outcomes in individual discussions with
the perioperative physicians, patients authorize those physicians
to use their clinical judgments to determine how specific interventions
will affect achievement of these goals.
The strength of the goal-directed approach is that physicians
should feel that they could truly honor the patient's desires
without having to worry about getting caught in a technicality
inconsistent with the patient's desires. Even better, predictions
about the success of interventions that are made by the anesthesiologist
at the time of the resuscitation are likely to be more accurate
than predictions made preoperatively, when the quality and nature
of the problems are not known.
Goal-directed orders work well for patients who want their perioperative
caregivers to customize the extent of resuscitation based on the
caregivers' understanding of the patients' goals for the postoperative
period. For this benefit, patients must accept the ambiguity that
comes with relying on caregivers to apply their assessments of
the clinical situations to their interpretations of the patients'
goals.
Postoperative Planning: Using the Opportunity to Withdraw
Care to the Patient's Advantage
While not included on the form, a useful adjunct to the decision-making
involved in perioperative resuscitation is the opportunity to
withdraw care. This option is available no matter which of
the options for perioperative resuscitation is chosen. The
ability to give the patient a trial of therapy, such as mechanical
ventilation, is one of the better ways to fulfill patients’ end-of-life
requests to be the recipient of resuscitative efforts without
the possibility of getting stuck on the ventilator. Choosing this
option, for example, is a way of declaring that the burden of
a few days of ventilatory support may be worth the potential benefit
of extubation of the trachea but that the burden of long-term
ventilation is not worth it, especially if there is a decreasing
likelihood of success. If the time-limited trial is deemed unsuccessful
in light of the declared goals, then mechanical ventilation may
be withdrawn. The act of withholding therapy requires greater
certainty in the likelihood that a therapy will fail than does
withdrawing a therapy after it has been shown to be unsuccessful.
Conclusion
Using a form with Options 1-4 will facilitate communication
and documentation. Its success still depends on the willingness
and ability of the caregivers to take the time to engage the patient
in discussion and to ensure that patients' well-documented wishes
are followed. DNR orders are predicated on the idea that patients
may choose to forgo certain procedures and their possible benefits
because they reject the associated burdens. The burdens may be
related to either the resuscitation attempt itself or to the decrement
in functional or cognitive capacity that may follow a successful
attempt at resuscitation. Discussions about perioperative resuscitation
should focus on determining which option best fits the patient's
views of the expected benefits and potential burdens.
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David
B. Waisel, M.D., is Assistant in Anesthesia, Children's Hospital,
Instructor in Anesthesia, Harvard Medical School, Department
of Anesthesia, Children's Hospital, Boston, Massachusetts.
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Robert
D. Truog, M.D., is Professor of Anesthesia (Pediatrics) and
Professor of Medical Ethics, Harvard Medical School and Director,
Multidisciplinary Intensive Care Unit, Children's Hospital,
Boston, |
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