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Making the Case for Perioperative Review of DNR Orders
Posted on: 11/29/2017

The perioperative period generally refers to the three phases of surgery:

  • Preoperative – occurring in the period before a surgical operation.
  • Intraoperative – occurring or performed during the course of a surgical operation/procedure.
  • Postoperative – the period following a surgical operation.

An 85-year-old male who has dementia needs partial hip replacement surgery following a fall at a long-term care facility. The patient has a do not resuscitate (DNR) order1 in his medical record. His spouse – the health care power of attorney – is adamant about enforcing her husband's wishes and directs that the DNR order stay in effect during the perioperative period. 

How would you handle this scenario?

Is it best to keep the DNR in place for the perioperative period? Can the medical team automatically suspend this patient's DNR order for the perioperative period? Alternatively, do doctors feel comfortable moving forward with an operation without any modifications to the patient’s DNR order?

Herein lies the challenge: What is the best strategy to accomplish the goal of a successful operation while respecting the patient's wishes?

Discussion

The balance of clinical care and resuscitation can quickly become complicated due to the overlap of provisions of care involved in providing an anesthetic and that clinical care which would be prohibited with the patient’s DNR order.

The DNR order, which is sometimes also referred to as "DNAR" (do not attempt resuscitation) or "AND" (allow natural death), may encompass a DNI (do not intubate) order. Strictly adhering to a DNR order without any consideration pertaining to the specific operation or procedure can be challenging for the medical team.

For example, certain surgical procedures may require intubation of the patient’s trachea to secure the patient's airway. If the patient is not amenable to intubation, the surgical procedure may not be able to be performed safely.

Furthermore, intubation, positive pressure ventilation and the intravenous administration of vasoactive medications might be used to treat transient decreases in blood pressure that may have been caused by the anesthetic itself. In other words, resuscitation methods prohibited by the patient's DNR might be used to reverse unintended effects caused by the operation/procedure or from the anesthetic.  

Therefore, physicians involved in the care of a patient should review and clarify the patient's wishes pertaining to resuscitation for the perioperative period before any impending procedure or surgery, and the administration of anesthesia.

Before any surgery or procedure, or administration of anesthesia, talk with your patients about their existing DNR order.

Finding the right strategy for success 

By clarifying the patients' wishes, the best strategy can then be determined to balance the goals for a successful operation while also respecting the wishes of the patient during the perioperative period, which can include these options: 

  • The patient may consent to a temporary suspension of the DNR order, allowing a full attempt at resuscitation under anesthesia and surgery.

  • Continuance of the DNR order without any modifications.

  • The patient may wish to temporarily modify the DNR order to allow specific but limited resuscitation attempts, procedures. For example, the patient may want intravenous administration of vasoactive medication – but no chest compressions or tracheal intubation.

  • The patient may allow the anesthesiologist and the surgeon to use their own judgments regarding resuscitation, consistent with the patient's objectives. A patient may state that his or her wish is that if the adverse events in the operating room are deemed to be temporary and reversible based on the clinical judgment of the physicians caring for the patient, these conditions would then fulfill the patient’s wishes for a full resuscitation.

Additionally, the time frame of the perioperative period must be crystal clear to all parties caring for the patient. Patients may want their DNR order modified or suspended until they leave the recovery room or for a specific number of hours/days after the procedure, etc.  Whatever is determined, the exact parameters must be documented in the medical record and communicated to all health care team members caring for the patient.  

Summary

While a complete suspension of the DNR order for the perioperative period removes any confusion for the medical team as to which type of resuscitation may be performed and which cannot, the patient's wishes must always be respected. The patient has the right to refuse unwanted treatment and to decide whether the benefits of being resuscitated outweigh the burdens of the resuscitation itself, which is the basis of the DNR order. 


If you have questions, please contact the ISMS Legal Department at 800-782-4767 or send an email. Please note that ISMS cannot provide legal advice, and private legal matters should be referred to your practice attorney.

Resources

The American Society of Anesthesiologists offers these resources:

Also access:

  • The Illinois Department of Public Health’s POLST form.

  • The Illinois State Medical Society's A Personal Decision, available as a free download.

ISMS member physicians may request up to 300 print copies of A Personal Decision per year – at no cost – for distribution to patients. Contact the ISMS purchasing department at 800-782-4767 or send an email. The cost for non-members to purchase 300 copies is $225. 

1recorded in an Illinois Department of Public Health's Uniform Practitioner Order for Life-Sustaining Treatment (POLST) form. 

2Copyright © 2001 American Society of Anesthesiologists; this document is reprinted with permission of the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973.

3Copyright © 2015 American Society of Anesthesiologists; this document is reprinted with permission of the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973.



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