October 2002
Volume 66 |
Number 10
|
| |
WHAT'S NEW IN …
|
|
Perioperative DNR Orders
David B. Waisel,
M.D.
Committee on Ethics
|
Why is it that the perioperative re-evaluation of do-not-resuscitate
(DNR) orders does not appear to be part of the clinical
landscape?
History of Perioperative DNR Orders
The formal history of perioperative DNR orders began in
1993 and 1994 when ASA and the American College of Surgeons,
respectively, published guidelines suggesting the re-evaluation
of DNR orders prior to the patient coming to the operating
room. ASA's first set of "Ethical Guidelines for the
Anesthesia Care of Patients With Do-Not-Resuscitate Orders
or Other Directives That Limit Treatment," approved
by the ASA House of Delegates on October 13, 1993, gave
the impression that the recommended method for performing
and documenting the re-evaluation was similar to the procedure-directed
orders used on the ward. The guidelines listed a number
of common therapies such as tracheal intubation, electrocardioversion
and pharmacologic therapy, which the patient chose with
the guidance of anesthesiologists, surgeons and other caregivers.
Anecdotal evidence suggested that these guidelines had
little impact on patient care. The failure was likely multifactorial.
Hospital policies lagged. Anesthesiologists and surgeons,
untrained in managing perioperative DNR orders, were more
comfortable reverting to the familiar automatic revocation
of the DNR order. Perhaps most importantly, the procedure-directed
approach was deemed unwieldy and too likely to create situations
in which the letter and intent of the directive would conflict.
Five years later, ASA modified its DNR guidelines to include
a goal-directed approach to perioperative DNR orders. This
approach encouraged relevant caregivers to discuss with
the patient his or her preferences for resuscitation on
three axes: quantitative likelihood of various outcomes,
the qualitative aspects of those outcomes and their meaning
to the patient and the burden of reaching these various
quantitative and qualitative outcomes. The operating room
caregivers (such as the surgeon and anesthesiologist) then
act as fiduciary representatives with expert knowledge to
determine if continued therapy would be consistent with
the patient's wishes.
In practice, patients who wish to retain their DNR orders
choose to request "resuscitative efforts during surgery
and in the postoperative care unit only if the adverse events
are believed to be both temporary and reversible, in the
clinical judgment of the attending anesthesiologists and
surgeons." This approach limited potential inconsistencies
that may arise with procedure-directed orders. It also came
closer to honoring the patient's wishes in that theories
and assumptions about the success of therapies could be
tested at the time rather than just predicted as in the
procedure-directed orders. This approach was complemented
by the ability to withdraw care in the postoperative period
if continued care was unlikely to achieve desired goals.
Since it is often difficult to determine if an event is
temporary and reversible, operating room caregivers could
continue with resuscitation and then determine later if
continued care is appropriate.
Perioperative DNR Orders: An Empty Suit?
To this point, the assumption has been that education, better
policies and the production of perioperative DNR forms (informed
consent form) will lead to increased individual and
administrative acceptance and use of perioperative DNR orders.
Despite these interventions, however, resistance to perioperative
re-evaluation of DNR orders remains. In order to determine
how the discussion about perioperative DNR orders should
proceed, it is necessary to characterize this resistance.
The following is a survey of possible causes.
Growing Pains
Some suggest there is no problem. Ward DNR orders took a
number of years to develop workable systems, and it was
not until appropriate systems were developed and a generation
of physicians grew up with the concept of withholding care
that DNR became a viable option.
Fundamental Disagreement
Discomfort about withdrawing treatments may be based on
personal beliefs and values. Anesthesiologists may believe
that beginning a treatment binds them to a responsibility
for continuing that treatment; to discontinue treatment
would mean a breach of expectations or that they have personally
failed in their duties to the patient. These views may be
compounded by the erroneous belief that anesthesiologists
are likely to be sued if they permit a patient with a well-documented
perioperative DNR order to die.
Too Hard
Anesthesiologists may agree in theory with perioperative
re-evaluation of DNR orders but find that putting theory
into practice is too complex. Hospital policies may not
elucidate the patient's right to refuse care or may not
provide a functional mechanism for re-evaluation and documentation.
Anesthesiologists may manage this issue too rarely to develop
sufficient expertise. For example, they may be perplexed
by the idea that because anesthesia promotes physiologic
instabilities to which the anesthesiologist routinely responds,
it is not possible to define the point at which anesthesia
ends and resuscitation begins. In fact, the guidelines'
goal-directed approach to perioperative DNR was developed
in part to avoid this question. Furthermore, production
pressure and lack of time to engage in the necessary discussions
may render even effective policies and knowledgeable individuals
ineffective. Finally, as a practical point, anesthesiologists
are often the last to interact with the patient. If the
surgeon has set the tone regarding re-evaluation (particularly
if the order is to be revoked), the die generally has been
cast.
Superfluous
Re-evaluation of DNR orders rarely leads to the maintenance
of a perioperative DNR order. Thus, it may be that this
is simply too rare an occurrence to attract the attention
of anesthesiologists. Moreover, it may be argued that if
goal-directed perioperative DNR orders hinge on the successful
withdrawal of care in the postoperative period, it may be
reasonable to revoke the DNR for the perioperative period
and focus on the appropriate withdrawal of care in the postoperative
period.
Seeking Help
The current guidelines, last amended on October 17, 2001,
are available for viewing on the ASA Web site at < www.asahq.org/Standards/09.html
>. Please take some time to review them, and then let us
know how they do (or do not) affect your practice.
It is said that the executives of the "big three"
American automobile manufacturers overlooked the international
challenge to their supremacy several decades ago because
everywhere they went in Detroit they saw American-made cars
– on the road, in the parking lot and in their neighbors'
garages. The executives did not realize that all these people
worked for the "big three" (or at least lived
in Detroit where it was heretical to drive a non-American
car), and the rest of the country was moving to imported
cars.
Those of us who think and write about perioperative DNR
orders may have similar blind spots. We talk primarily to
each other; we work in our own little Detroits. I worry
that we could be missing the boat. I encourage readers to
respond to me with their thoughts at .
Bibliography:
American Society of Anesthesiologists. Ethical Guidelines
for the Anesthesia Care of Patients With Do-Not-Resuscitate
Orders or Other Directives That Limit Care. 2001. < www.asahq.org/Standards/09.html
>
Bastron RD. Ethical concerns in anesthetic care for patients
with do-not-resuscitate orders. Anesthesiology. 1996; 85:1190-1193.
Cohen CB, Cohen PJ. Do-not-resuscitate orders in the operating
room. N Engl J Med. 1991; 325:1879-1882.
Margolis JO, McGrath BJ, Kussin PS, Schwinn DA. Do not
resuscitate (DNR) orders during surgery: Ethical foundations
for institutional policies in the United States. Anesth
Analg. 1995; 80:806-809.
Truog RD. Do-not-resuscitate orders during anesthesia and
surgery. Anesthesiology. 1991; 74:606-608.
Truog RD, Waisel DB, Burns JP. DNR in the OR: A goal-directed
approach. Anesthesiology. 1999; 90:289-295.
| |
|
David
B. Waisel, M.D., is Assistant Professor of Anesthesia,
Harvard Medical School, Boston, Massachusetts. |
|
return to top
|