Abstract
Background
B
Policies
The Association of Perioperative Registered Nurses (AORN), 1 the American College of Surgeons (ACS), 2 and the American Society of Anesthesiology (ASA) 3 all have position statements on the status of DNR orders in ORs. There is firm agreement among them that health care institutions should promote opportunities for a careful, informed discussion about potential resuscitative measures between the patient or surrogate, surgical team, and anesthesia team, before a planned procedure, in order that a treatment approach best matches the patient's goals of care and medical situation. There is agreement that policies that automatically suspend DNR orders in the OR are inappropriate if they do not mandate an informed consent discussion with the patient/surrogate or factor in the risk/benefit profile of the intervention.
Causes and Outcomes of Cardiac Arrest in the Operating Room
National in-hospital resuscitation registry data suggest that survival from CPR is higher in the perioperative setting versus other in-hospital setting: asystole 30.5% versus 10.0%; pulseless electrical activity 26.4% versus 10.0%; pulseless VT/VF 41.9% versus approximately 34%.4,5 The overall frequency of perioperative cardiac arrests in patients undergoing noncardiac surgery is 4.3 per 10,000 anesthetics (0.00043%), with even lower cardiac arrest rates attributable to anesthesia (approximately 0.5 per 10,000). In a single-center study, 35.0% of cardiac arrests in the OR were due to bleeding, 43.9% were related to cardiac causes, and 21.1% were attributable to other causes, with hemorrhage having the poorest outcome. 6
Balancing Ethical Precepts
Patient autonomy is paramount to ethical decision making. Indeed, concerns about differential treatment once a DNR order is in place may make a patient hesitant to pursue such a directive. 7 Still, there are considerations that may lead surgical teams and anesthesiologists to hesitate when adopting “no resuscitation efforts,” especially for risky surgeries. Anesthesiologists are often resuscitating patients in an ongoing fashion via titration of vasopressors and other life-sustaining therapies; hence there may not be a clear line between normal anesthesia management and intraoperative resuscitation. Surgical teams may view their primary objective in the OR as to provide care that sustains survival during the procedure. Thus, intraoperative deaths in the setting of a DNR order may not only contribute to feelings of guilt, but may also lead to quality reviews and a negative impact on quality metrics such as 30-day mortality rates. Regardless, most important to achieving balance among these concerns is an open discussion among relevant parties that allows patients to negotiate their treatment preferences while attaining the input of the anesthesia and surgical teams with regards to how specific treatment preferences may affect their care during the proposed procedure.
Required Reconsideration of Do-Not-Resuscitate Orders
Instead of a policy that leads either to the automatic enforcement or cancellation of a DNR order in the OR, the American College of Surgeons (ACS) recommends that a “required reconsideration of DNR orders” discussion be incorporated systematically prior to a proposed procedure.
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During such a discussion, the surgical/anesthesia team should clearly delineate to the patient or surrogate which resuscitative efforts are felt to be essential to the success of the proposed procedure and which are not. They should also describe the challenges in discerning routine anesthesia management in the OR from resuscitative efforts as well as the more favorable outcomes of cardiac arrests in the OR. Based on the patient/surrogate's goals of treatment and the nature of the surgical procedure, the intent of such a discussion is to achieve a mutually agreeable operative and perioperative management approach. Potential outcomes could include:
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• The DNR order is rescinded during surgery and the perioperative period and the patient consents to the use of any resuscitation procedure needed to treat the clinical events that occur. • The original DNR order is maintained and prior treatment limitations are upheld. • The DNR order is modified such that limited attempts at resuscitation are clearly defined with regards to specific procedures. • The patient and surrogate allow the anesthesiologist and surgical team to use clinical judgment in determining which resuscitation procedures are appropriate in the context of the situation and the patient's stated goals of care.
Changes or clarifications should be documented in the medical records and discussed with the members of the operating room staff.
Ethical or Professional Conflict
When any member of the team disagrees with the management approach established, he or she may withdraw from the patient's care in a nonjudgmental fashion. If agreement on a surgical care strategy cannot be achieved, the surgeon should consider a referral to another surgeon or institution and/or provide an alternative for care. In such scenarios, palliative care and/or bioethics consult teams may be of assistance to patients and clinicians.