Do-Not-Resuscitate in the OR

In 1974, the concept of “Do Not Resuscitate (DNR)” orders emerged to address cases of terminal illness where death is anticipated [3]. Hospitals swiftly integrated these orders into their policies, requiring formal documentation in patient records for those who are eligible and choose to exercise this right [3]. Today, healthcare professionals may have to grapple with the challenge of surgical patients with preexisting DNR orders, with the potential for uncertainty in managing such advance directives [1]. Questions surface regarding the suspension of DNR orders before surgery and the risk surgeons face when operating on such patients [1]. With an estimated 15% of patients with DNR orders undergoing surgery, it is necessary to address the complexities of Do-Not-Resuscitate in the OR setting [1,2].

A DNR order is considered when a patient decides to decline CPR, deeming it ineffective, or when the burdens of CPR outweigh the benefits [1]. This decision is reached in collaboration between the physician and the patient (or surrogate if the patient lacks capacity) [1]. Patients and families must be well-informed about CPR procedures and outcomes [1]. In the OR setting, where resuscitative efforts are often more successful, reevaluation of a Do-Not-Resuscitate order is paramount [1]. While in-hospital CPR outcomes are relatively poor, with 40% achieving return of spontaneous circulation (ROSC), 10% of those patients surviving to hospital discharge, and 25% of discharged patients living beyond five years, resuscitation in the OR can achieve an impressive 92% recovery rate when the arrest is due to anesthetic medications [1]. This underscores the importance of revisiting a patient’s DNR decision, particularly within the perioperative period [1].

Numerous professional healthcare organizations provide guidance on Do-Not-Resuscitate orders in the OR setting [2,3]. The American College of Surgeons emphasizes a “required reconsideration” policy for advance directives, highlighting the importance of patient-physician discussions, documentation, and communication with the surgical team [2]. The American Medical Association stresses patient expression of treatment preferences and periodic revisions, outlining the procedures involved in resuscitation [2]. The American Society of Anesthesiologists underscores patients’ right to self-determination, opposing the automatic suspension of DNR orders in the operating room and instead advising directive review, clarification, and sharing with the healthcare team [2]. This issue is especially relevant for anesthesiologists, given the extreme but reversible effects of many anesthetic medications [2]. During the perioperative period, it may be impossible to distinguish between a cardiac arrest resulting from the administration of anesthetic medication, the performance of the procedure, or a natural progression of the patient’s primary disease [2]. As a result, many hospitals continue to have policies automatically suspending DNR orders in the perioperative area [2].

The National Center for Ethics in Health Care notes that when a patient with a DNR order schedules surgery or anesthesia-related procedures, questions may arise about the appropriateness of interventions like intubation and mechanical ventilation [2]. There is a tension between the obligation to respect the patient’s decision to forgo specific treatments and the obligation of the surgical team to provide quality perioperative care [2]. The decision to suspend or not suspend a DNR order during the perioperative period involves both clinical and ethical considerations, making it imperative for these choices to result from shared decision-making between the surgeon and the patient or their surrogate decision-makers [1].

References

1. Shapiro, M., & Singer, E. (2019). Perioperative advance directives: Do not resuscitate in the operating room. Surgical Clinics, 99(5), 859-865.

2. Byrne, S., Mulcahy, S., Torres, M., & Catlin, A. (2014). Reconsidering do-not-resuscitate orders in the perioperative setting. Journal of PeriAnesthesia Nursing, 29(5), 354-360.

3. Truog, R., Waisel, D., & Burns, J. (2005). Do-not-resuscitate orders in the surgical setting. The Lancet, 365(9461), 733-735.