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Perioperative Do-Not-Resuscitate Orders

Opportunity Knocks

Jacobs, Jeffrey S. MD

doi: 10.1213/XAA.0000000000000281
Editorials: Editorial

From the Department of Anesthesiology, Cleveland Clinic, Weston, Florida.

Accepted for publication October 5, 2015.

Funding: None.

The author declares no conflicts of interest.

Address correspondence to Jeffrey Jacobs, MD, Department of Anesthesiology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331. Address e-mail to

In this issue of A & A Case Reports, Hadler et al.1 address perioperative advance directives in the article “Advance Directives and Operating: Room for Improvement.” Although their research and survey questions were straightforward, their findings were disquieting. In 2015, despite the mandate to teach medical ethics and having robust resources available to do so, physician anesthesiologists are still confused about one of the basic principles of bioethics: patient autonomy. The topic of perioperative do-not-resuscitate (DNR) orders has been addressed, discussed, and enacted as policy by many medical societies and in many healthcare facilities, but it is unknown to and unheeded by many practitioners, including those who educate the next generation of anesthesiologists. Some facilities have not yet adopted the recommendations by the American Society of Anesthesiologists and the American College of Surgeons (which are nearly identical) for fear of legal repercussions such as wrongful death. This notion is antiquated and no longer relevant as a lawsuit, because wrongful “life” may be more likely in these situations.

Despite the inconsistencies in policy implementation, one of the most concerning things I identified in this article was the comment from a senior attending quoted in the study when referring to the discussion of DNR orders as being “…not part of my job.” I do not just see this as an important responsibility of anesthesiologists, but I view this as an ideal opportunity for our specialty. Although anesthesiology has made continuous advancements in science and technology, physician anesthesiologists must evolve beyond the operating room and include bioethics in this progress. This will necessitate collaboration with other physicians, which is a hallmark of the Affordable Care Act: more health care will need to be team-based and coordinated. There will be less “It’s not my job” and more “Let’s work together to care for the patient.” An additional alteration ensuing from the Affordable Care Act will involve standardization of patient care. All these changes will affect payments for care, which will no longer be procedure-focused; they will be outcome-driven and shared among the entire healthcare team. This will require anesthesiologists to be integrally involved in all aspects of the patient’s care.

The opportunities for these interfaces will come in many forms: coordination of patient care, administration of the organization, and, yes, even synchronization of ethical management. Specifically for the latter topic, who is better than anesthesiologists to harmonize care? Who is better able to understand preoperative disease processes, intraoperative considerations, and postoperative expectations? Who is better able to bridge medical thought and surgical action? Who is better to close the gap between physicians and nonphysician healthcare staff? I proffer that it is physician anesthesiologists, and when those opportunities arise, they should be warmly received and welcomed. In fact, these opportunities should be sought. Other ethical venues in which anesthesiologists can lead the hospital may be similarly less than intuitive but equally important. The facility’s institutional review board (specifically with informed consents for research) would be an ideal place in which an anesthesiologist could contribute. Another task could be the review and development of Jehovah’s Witness policies. Pandemic management (such as Ebola) is ideally suited for anesthesiologists just as is the management of drug shortages. Organ transplantation planning and implementation should have anesthesiologists involved from the onset. These are but a few examples of ways in which anesthesiologists can integrate themselves into their institution’s fabric.

This study should be viewed as a watershed moment in our specialty. It highlights our history, and it defines our future. The transition from operating room physicians to periprocedural care coordinators is upon us, and we need to embrace this advancement. The perioperative DNR order is the tolling bell that is calling us to action. This attitude begins with the development and implementation of cutting-edge residency curricula, innovative American Board of Anesthesiology requirements, and receptiveness of training program attending physicians to these changes. This attitude and practice need to be embraced in community hospitals and surgery centers led by practicing anesthesiologists who believe their duty to patients is not bound by the operating room door but is instead limitless in scope. Bioethics, the field that permeates our every action and every emotion, is one of our greatest opportunities to lead the healthcare team during this exciting time. The ball is in our court; let us not squander this gift.

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1. Hadler RA, Neuman MD, Raper S, Fleisher LA. Advance directives and operating: room for improvement? A&A Case Rep. 2016;6:204–7
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