Episode Transcript
Hello everybody. My name is Dr. Robb Wasserman. I am an assistant clinical professor at the University of North Carolina who specializes in general anesthesiology. Today, I would like to talk to you about the perioperative management of patients with do-not-resuscitate and do-not-intubate orders. Over the next 10 to 15 minutes, we will go over how the ethical guidelines for the anesthesia care of patients with do-not-resuscitate and do-not-intubate orders were formulated, how they are to be used, and what should be done if conflicts regarding following them should arise. By the end of this podcast, you should have an understanding of how to ethically manage patients with do-not-resuscitate/do-not-intubate orders, as well as the ability to identify potential barriers to anesthesia care for patients with these orders in place. Let’s get started.
First, I would like to talk to you about what exactly are do-not-resuscitate or do-not-intubate orders. These orders are legal documents stating a patient’s wishes surrounding their medical care should they be no longer able to make decisions about their care on their own due to an injury or a serious illness (these are also known as an advanced directives). Specifically, a do-not-resuscitate order would state that a patient does not want cardiopulmonary resuscitation (i.e. chest compressions, defibrillation, administration of specific medications and/or fluids and blood products) if their heart were to stop, and a do-not-intubate order would state that a patient does not want to be intubated if their breathing were to stop.
Now that we have established what exactly a do-not-resuscitate or a do-not-intubate order is, let’s discuss why specific decisions regarding how they are to be followed is required in the operating room. The operating room is an environment and circumstance unlike anything else in a patient's life. In fact, resuscitation may seem routine and fundamental for an anesthesiologist caring for a patient in the operating room. Inhaled and intravenous anesthetics often lead to hypotension, myocardial depression, respiratory depression, and/or cardiac arrhythmias and what we do to "resuscitate" the patient experiencing these events is very routine, in contrast to the measures needed for resuscitation in other environments. Surgery and anesthesia are times of higher risk that often will revert back to normal shortly after the procedure. With that in mind, a DNR order may seem in opposition of our duties as an anesthesiologist to do no harm. Because of this, prior to the 1990s, DNR orders were routinely suspended during the perioperative period. A big reason for this was due to us as health care professionals. Simply put, it is hard on us to not do everything possible to help save the patient. This is what we have been trained to do. Not only this, but as an anesthesiologist, our administration of anesthesia medications may have precipitated the cardiovascular collapse, thus providing us with a greater urge to help save the patient. As such, formal policies to suspend DNR orders were rare and decisions were basically left to the attending surgeon and/or anesthesiologist. In fact, many hospitals and institutions had policies that would automatically suspend the DNR order when a patient presented for surgery. In 1991, several articles were published, criticizing this practice. The major concern being that a patient was losing their autonomy and right to self-determination with the automatic suspending of a DNR order during the perioperative period. Finally, in October 2001 the American Society of Anesthesiologists published guidelines regarding the care of patients with DNR orders with special considerations to elective vs emergent situations and for competent vs incompetent patients. These guidelines were reaffirmed in 2008, 2013, and again in October 2018. These guidelines specifically state that hospital policies that automatically suspend DNR orders for the operating room should be reviewed and revised since they are in direct opposition to a patient’s right to self-determination.
In regards to caring for patients with DNR orders, we as physicians must always apply a few principles of ethics that can potentially seem at odds with each other. The first principle is the patient's autonomy or the patient's right to self-determination. Simply put, a patient has the right to refuse treatment for any reason. An excellent and common example of this is a Jehovah's witness refusing blood products due to their religious beliefs. Then there are the principles of nonmaleficence and beneficence. "First, do no harm" and do good for the patient while also removing them from harm. These principles have been engrained in us as physicians since day one of medical school. But what happens when the principles of beneficence/nonmaleficence are at odds with patient autonomy. This can put us, as providers, in an uncomfortable situation. An example of this would be a patient who states that they do not want to be intubated under any circumstances and is scheduled to undergo a procedure with a native airway and deep sedation. Providing anesthesia to such a patient while respecting their autonomy could potentially expose them to excessive harm.
The discussion with a patient prior to their procedure is of critical importance.
When caring for a patient with a DNR in place, per the Statement on Ethical Guidelines of the Anesthesia Care of Patients with Do-Not-Resuscitate Orders from the ASA, one of three pathways should be followed.
The first is known as Full Attempt at Resuscitation. Here I am just going to quote the ASA statement to avoid any possible confusion. "The patient or designated surrogate may request the full suspension of existing directives during the anesthetic and immediate postoperative period, thereby consenting to the use of any resuscitation procedures that may be appropriate to treat clinical events that occur during this time".
The second pathway is known as Limited Attempt at Resuscitation Defined with Regard to Specific Procedures. Here "the patient or designated surrogate may elect to continue to refuse certain specific resuscitation procedures (for example, chest compression, defibrillation or tracheal intubation). The anesthesiologist should inform the patient or designated surrogate about which procedures are 1) essential to the success of the anesthesia and the proposed procedure, and 2) which procedures are not essential and may be refused.”
The last pathway is known as Limited Attempt at Resuscitation Defined with Regard to the Patient's Goals and Values. Here "the patient or designated surrogate may allow the anesthesiologist and surgical/procedural team to use clinical judgment in determining which resuscitation procedures are appropriate in the context of the situation and the patient's states goals. For example, some patients may want full resuscitation procedures to be used to manage adverse clinical events that are believed to be quickly and easily reversible, but refrain from treatment for conditions that are likely to result in permanent sequelae, such as neurologic impairment or unwanted dependence upon life-sustaining technology"
No matter which pathway the patient decides to pursue after discussion with their care team, it is of the upmost importance that this conversation and the patient's wishes with regards to their care during the perioperative are thoroughly documented in the patient's medical record. If any suspending of the patient's do-not-resuscitate order occurs, it is also of vital importance to establish if and when the order is to be reinstated (be that when the patient leaves the post anesthesia care unit or when the patient has fully recovered from the effects of anesthesia and/or surgery.). Agreement with the plan regarding the patient's wishes should be discussed and fully agreed upon by the patient’s primary physician, the surgeon/proceduralist, the anesthesiologist, and all other members of the patient's health care team if possible.
What happens if a disagreement with the plan regarding the patient’s wishes should occur within the care team, however? Should a conflict arise, the ASA Statement on Ethical Guidelines recommends three resolution processes. 1) If the anesthesiologist own moral views are irreconcilable with the patient's or surgeon's limitations of intervention decisions, the anesthesiologist should withdraw in a nonjudgmental fashion and be replaced in a timely manner. 2) If the generally accepted standard of care is in opposition to the patient's or surgeon's limitation of intervention decisions, the anesthesiologist should make said concerns known to the appropriate institutional body. And 3) if the previously stated alternates are not possible then one should proceed with adherence to the patient's wishes with the patient's goals and values in mind.
Let’s go over a specific scenario now just to drive home some of the key points here. Our patient is a 73-year-old male with a history of metastatic pancreatic cancer. He presents to the operating room for gastrostomy tube placement due to his inability to tolerate PO nourishment. He has a do-not-resuscitate order in place. How should you proceed?
First and foremost, you, as the attending anesthesiologist, must have a conversation with the patient regarding how they would like to handle their DNR order during the procedure. Would the patient like to proceed with full suspension of their DNR order and proceed would a “full attempt at resuscitation”. Would they like to proceed with a “limited attempt at resuscitation defined with regard to specific procedures”? Or would they like to proceed with “limited attempt at resuscitation defined with regard to the patient’s goals and values”? After discussion with the patient, he decides he would like to proceed with limited attempt at resuscitation defined with regard to specific procedures in that he would specifically like no chest compressions or defibrillation, but he is OK with tracheal intubation and all medications and fluids/blood products for resuscitation. This conversation and the patient’s wishes must then be documented in the patient’s chart and discussed with the entire care team so everyone is on the same page. It then must be made clear when the patient would like their DNR order re-instated. After discussion with the patient, he decides he would like the DNR order to be re-instated the moment he leaves the post anesthesia care unit. This again must be documented in the chart and discussed with the care team. Now that this has been discussed, the patient has made his wishes known, and it has been thoroughly documented, you may proceed with the case knowing that if the need were to arise, no chest compressions or defibrillation should be performed on the patient per their wishes. If you follow this discussion pathway for every patient with a DNR or a DNI order in place, you will hopefully successfully address a patient’s rights to self-determination in an ethical manner.
Thank you so much for taking the time to listen to this Anesthesia Toolbox podcast on the perioperative management of patients with do-not-resuscitate and do-not-intubate orders. I hope it was informative.
