ne of the fundamental principles of medical ethics and of American law is that each patient has the right to determine what happens to his/her personhood, mind and body. The ethical principle is respect for the personal autonomy of every patient. The legal precedent is that patients are entitled to enough information for them to develop an informed consent to medical procedures. The legal precedent was established by Judge Benjamin N. Cardoza (Schloendorff v. Society of New York Hospital, 1914) in a case in which a patient consented to an abdominal examination under anesthesia but specifically refused any surgery; the surgeon performed a hysterectomy, which he felt was indicated.¹ The legal right to refuse medical treatment and interventions has been repeatedly upheld since that time in many U.S. legal proceedings (e.g., Natanson v. Kline, 1960).²

Membership in ASA carries with it the obligation to respect patients’ autonomy and obligates physicians to engage patients in an informed consent process before providing elective anesthetic care. These obligations are described in the ASA Guidelines for the Ethical Practice of Anesthesiology (Section I, 1 and 2) and in Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders. Both House of Delegates-approved documents are available for free on the ASA Web site at www.ASAhq.org under “Clinical Information.”

“Do not attempt resuscitation” (DNAR or DNR) is an informed refusal of resuscitation from the sudden, often unexpected, arrest of breathing and/or circulation. It expresses the patient’s wish to forego cardiopulmonary resuscitation measures that include securing an unobstructed airway, positive pressure ventilation, sternal compression, electrical defibrillation and the administration of drugs, often in large doses, to restore normal breathing and circulation.

Note that DNR requests do not preclude any ongoing treatments supportive of vital organ function. In fact, such measures can be increased and added to as necessary to maintain homeostasis as close to normal as possible. Withholding and withdrawing such supportive therapies when they have proved to be nonbeneficial are the subjects of advance directives. Typically patients with specific directives for their care will execute a living will and/or appoint a surrogate with durable power of attorney for health care decision-making. (Note that in this article, “surrogate” is implied whenever “patient” is mentioned for situations in which the patient cannot speak for him/herself.)

Many of the measures used in cardiopulmonary resuscitation (CPR) are the same ones that anesthesiologists employ in the setting of anesthesia care when a patient exhibits cardiopulmonary insufficiency resulting from the administration of anesthetic drugs and interventional manipulations superimposed on the patient’s comorbidities. Hence the presentation of a patient with DNR status creates both a dilemma and discomfort for the anesthesiologist and others involved in the patient’s care. All physicians and nurses have a duty to treat each patient with respect, abide by the patient’s wishes (autonomy), avoid harming the patient (nonmaleficence) and do their best to preserve life and well-being (beneficence). The dilemma for health care workers usually comes down to a perceived conflict between the principles of respecting autonomy versus providing beneficent care. Not all patients value prolongation of life in all circumstances. A mark of true health care professionals is that they respect the vulnerable patient’s decisions above their own discomfort.

So what is to be done when a “DNR patient” is to undergo anesthesia care? For electively scheduled interventions, there are three basic options:

1) Maintain DNR, which is appropriate for a strictly palliative intervention even when an iatrogenic injury occurs.³

2) Suspend DNR and allow a full attempt at resuscitation during the intervention and for a period of time typically sufficient to allow recovery from the effects of the intervention and the residual effects of anesthetic drugs. Certain interventions (e.g., cardiac surgery) require suspension because they can only be accomplished with the routine use of resuscitation methodologies.

3) Modify the DNR conditions to allow a limited attempt at resuscitation according to

a) specific procedures that the patient will/will not allow or

b) the patient’s goals and values. In this case, the patient places his/her trust in the physicians to use their clinical judgment to treat easily reversible adverse events that most likely have no long-term adverse consequences, and physicians are trusted to refrain from treatment of conditions that are likely to result in permanent sequelae such as neurological impairment or long-term dependence on technologic support of vital functions.

Anesthesiologists can inform patients that CPR has a higher success rate and lower permanent injury incidence when it occurs during anesthesia care.

Obviously these options and the related decisions may become the determinants of the timing of death. The patient should clearly understand and be able to relate in his/her own words an understanding of terms (e.g., DNR, CPR) and what the terms imply for the potential timing and immediate causes of his/her death. Anesthesiologists should encourage and expect surgeons to address a patient’s DNR status well before he/she is scheduled to arrive at the operating room door. Discussions of the options and making decisions take time and are best accomplished well in advance of an electively scheduled intervention (e.g., preanesthesia clinic, advance request for anesthesiology consultation).

Ideally there would already be a note on the patient’s chart by the surgeon or the patient’s primary physician that describes the perioperative plan for maintaining or for temporarily suspending and reinstating DNR requests.⁴ Whether or not such a note has been written, the anesthesiologist should write a note in the chart acknowledging his/her understanding of the patient’s wishes. For example it could state: “This patient seems to understand that adequate anesthesia care could be impaired by continuation of her/his DNR status. Ms. Anna Smith would like to suspend her DNR status during the tracheostomy and postoperatively until the effects of the anesthesia have dissipated, but no later than 24 hours postoperatively, at which time the patient requests that her DNR status be fully reinstated.”

The ideal is to respect the patient’s informed and longstanding wishes. “Importantly, being autonomous does not merely involve being competent and making a choice — it involves constructing a concept of how one’s life should go according to a coherent set of values.”⁵ A patient’s primary physician would be best situated to understand a patient’s coherent values. Because fewer and fewer patients have their own primary care physician as their attending during a hospitalization, however, the responsibility for understanding and adhering to patients’ requests for limitations on treatment falls to the anesthesiologists and surgeons who are asked to care for them.

Automatic suspension of DNR status as a matter of institutional policy or personal preference of a surgeon or anesthesiologist does not sufficiently address the patient’s rights to self-determination in a responsible, ethical and legal manner. When there is real doubt about a patient’s understanding of his/her DNR status at the time immediately before the scheduled start of the elective intervention, there are only two options:

a) to delay the intervention until the patient has a clear understanding of the options and their implications and can make his/her decision consistent with his/her own values; or

b) to inform the patient that it is the opinion of the anesthesiologist and the other physicians involved that the only alternative to postponing the intervention is to suspend the DNR status in order to avoid an irreversible decision to omit CPR measures.

Although this choice seems coercive, it is the only way to meet the professional oaths of the physicians to avoid potentially irreversible harm to the patient (e.g., death, neurological impairment).

All medical and surgical practices today are “team sports.” All those involved contribute to the well-being of the patient by following best practices for their area of responsibility, which interacts with and affects the responsibilities of other members of the team. The two responsible physicians in the operating room are the surgeon and the anesthesiologist. They share responsibility for the patient’s care and its outcome. (Just ask any trial lawyer!) Both should be well informed about the patient’s goals and expectations for the intervention (e.g., curative, restorative, palliative); and they both should have a clear understanding of the patient’s wishes in regard to what is/is not acceptable treatment. How else can the team function? How else can the patient’s best interests be served?

References:
1. Schloendorff v. New York Hosp., 211 N.Y. 125. 105 N.E. 92 (1914).
2. Nathanson v. Kline, 186 Kan. 393. 350 P.2d 1093 (1960).
3. Casarett D, Ross LF. Overriding a patient’s refusal of treatment after an iatrogenic complication. N Engl J Med. 1997; 336:1908-1910.
4. American College of Surgeons: [ST-19] Statement on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room. www.facs.org/fellows_info/statements/st-19.html.
5. Ward M, Savulescu J. Patients who challenge. Best Practice and Research, Clinical Anaesthesiology. 2006; 20:548.

Carl C. Hug, Jr., M.D., Ph.D., is Professor of Anesthesiology Emeritus and Faculty Associate in the Ethics Center, Emory University, Atlanta, Georgia.

Susan K. Palmer, M.D., is Medical Director of Anesthesia Services, McKenzie-Willamette Medical Center, Oregon Anesthesiology Group, Springfield, Oregon.