Advertisement

Perioperative Considerations of Do Not Resuscitate and Do Not Intubate Orders in Adult Patients

  • Joseph F. KrasEmail author
Chapter
  • 649 Downloads

Abstract

The vast majority of medical orders are for the purpose of some action being taken; for example, orders to admit patients to the hospital and orders to administer medications. DNR (Do Not Resuscitate) and DNI (Do Not Intubate) orders, however, are exceptions to these medical orders that initiate an action. DNR and DNI orders in the perioperative period may pit patients’ rights to decide which actions are (or are not) performed on their bodies against the surgeon and anesthesiologist’s duties to do their best to treat patients and to do no harm.

Autonomy figures prominently in Western medical ethics and, especially, in the United States (US). Patients should be able to directly (or through their surrogate) express their wishes for what type(s) of care they wish provided to them. Automatic suspension of DNR orders compromises patients’ abilities to decide their own fate.

Surgeons may feel duty-bound by the principle of beneficence to only perform actions that will physically benefit patients and feel, that by requesting surgery, patients implicitly want their surgeon to “get them through” the surgery, no matter what. Such an attitude would preclude letting patients die on the operating room table if they could be saved by cardiopulmonary resuscitation. Anesthesiologists often feel guided by nonmaleficence, going so far as to say that they “don’t want to be a patient’s executioner.” Like many of their surgical colleagues, they view standing by while patients die from potentially totally reversible events as being totally antithetical to their calling.

Keywords

Perioperative Do Not Resuscitate Do Not Resuscitate Suspending Do Not Resuscitate Perioperatively Surgery and Do Not Resuscitate 

References

  1. 1.
    Raghavendra T. Neuromuscular blocking drugs: discovery and development. J R Soc Med. 2002;95:363–7.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Berthelsen P, Cronqvist M. The first intensive care unit in the world: Copenhagen 1953. Acta Anaesthesiol Scand. 2003;47:1190–5.CrossRefPubMedGoogle Scholar
  3. 3.
    Safar P, Escarraga L, Elam J. A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods. New Engl J Med. 1958;258:671–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Safer P. From control of airway and breathing to cardiopulmonary-cerebral resuscitation. Anesthesiology. 2001;95:789–91.CrossRefGoogle Scholar
  5. 5.
    Kouwenhoven W, Jude J, Knickerbocker G. Closed-chest cardiac massage. JAMA. 1960;173:1064–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Safar P, Brown T, Holtey W, Wilder R. Ventilation and circulation with closed chest cardiac massage in man. JAMA. 1961;176:574–6.CrossRefPubMedGoogle Scholar
  7. 7.
    Monahan J, Lawhorn E. Life-sustaining treatment and the law: the evolution of informed consent, advance directives and surrogate decision making. Ann Health Law. 2010;19:107–13. Art 23.PubMedGoogle Scholar
  8. 8.
    Schwarze M, Redmann A, Alexander G, Brasel K. Surgeons expect patients to buy-in to postoperative life support preoperatively: results of a national survey. Crit Care Med. 2013;41(1):1–8.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Pecanac K, Kehler J, Brasel K, Cooper Z, Steffens N, McKneally M, Schwarze M. It’s big surgery: preoperative expressions of risk, responsibility, and commitment to treatment after high-risk operations. Ann Surg. 2014;259:458–63.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Clemency M, Thompson N. “Do Not Resuscitate” (DNR) orders in the perioperative period-a comparison of the perspectives of anesthesiologists, internists, and surgeons. Anesth Anal. 1994;78(4):651–8.CrossRefGoogle Scholar
  11. 11.
    Burns J, Edwards J, Johnson J, Cassem N, Truog R. Do-Not-Resuscitate order after 25 years. Crit Care Med. 2003;31(5):1543–50.CrossRefPubMedGoogle Scholar
  12. 12.
    Burkle C, Swetz K, Armstrong M, Keegan M. Patient and doctor attitudes and beliefs concerning perioperative Do Not Resuscitate orders: anesthesiologists’ growing compliance with patient autonomy and self determination guidelines. BMC Anesthesiol. 2013;13:2. http://www.biomedcentral.com/1471-2253/13/2. Accessed 26 Feb 2015.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    General Medical Council. Treatment and care towards the end of life: good practice in decision making. 2010. http://www.gmc-uk.org/static/documents/content/Treatment_and_care_towards_the_end_of_life_-_English_0914.pdf. Accessed 12 Apr 2015.
  14. 14.
    Knipe M, Hardman J. Past, present, and future of ‘Do Not Attempt Resuscitation’ orders in the perioperative period. Br J Anaesth. 2013;111(6):861–3.CrossRefPubMedGoogle Scholar
  15. 15.
    Schaden E, Herczeg P, Hacker S, Schopper A, Krenn C. The role of advance directives in end-of-life decisions in Austria: survey of intensive care physicians. BMC Med Ethics. 2010;11:19. http://www.biomedcentral.com/1472-6939/11/19. Accessed 21 Feb 2015.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Santonocito C, Ristagno G, Gullo A, Weil M. Do-Not-Resuscitate order: a view throughout the world. J Crit Care. 2013;28:14–21.CrossRefPubMedGoogle Scholar
  17. 17.
    Chan WL. The “Do-Not-Resuscitate” order in palliative surgery: ethical issues and a review on policy in Hong Kong. Palliat Support Care. 2015. doi: 10.1017/S1478951514001370.Google Scholar
  18. 18.
    Saeed F, Kousar N, Aleem S, Khawaja O, Javaid A, Siddiqui M, Holley J. End-of-life care beliefs among Muslim physicians. Am J Hosp Palliat Care. 2014. doi: 10.1177/1049909114522687.PubMedGoogle Scholar
  19. 19.
    Gordon M. Cardiopulmonary resuscitation in the frail elderly: clinical, ethical and halakhic Issues. Isr Med Assoc J. 2007;9:177–9.Google Scholar
  20. 20.
    Buchman T, Cassell J, Ray S, Wax M. Who should manage the dying patient?: rescue, shame, and the surgical ICU dilemma. J Am Coll Surg. 2002;194(5):665–73.CrossRefPubMedGoogle Scholar
  21. 21.
    Schwarze M, Redmann A, Brasel K, Alexander G. The role of surgeon error in withdrawal of postoperative life support. Ann Surg. 2012;256(1):10–5.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    ACS NSQIP Program Specifics, Inclusion/Exclusion Criteria. http://site.acsnsqip.org/program-specifics/inclusionexclusion-criteria-4/. Accessed 2 Mar 2015.
  23. 23.
    Northwestern Medicine. Death within 30 days following vascular or general surgery. http://www.nmh.org/nm/quality-30-day-mortality-vascular-and-general-surgery. Accessed 2 Mar 2015.

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Department of AnesthesiologyWashington University School of MedicineSt. LouisUSA

Personalised recommendations