Do Not Resuscitate (DNR) orders are established by competent patients or appropriate surrogates to provide a mechanism for withholding specific resuscitative therapies in the event of a cardiopulmonary arrest. It is important for health care institutions to develop policies to deal with DNR orders in the setting of anesthesia and surgery as it is estimated that 15% of patients with DNR orders undergo a surgical procedure  and the frequency of DNR orders is increasing as the population becomes better informed about the Patient Self-Determination Act and advanced directives . Several surveys have documented confusion on the part of individual practitioners and have demonstrated that only a small percentage of institutions have specific policies regarding perioperative DNR orders [3-6]. This lack of consistency stems in part from the fact that surgery and anesthesia routinely involve physiologic stresses and suppression of vital signs far different from those experienced outside the operating room. The unique aspects of anesthesia create potential practical and ethical barriers to the implementation of perioperative DNR orders. In this paper, the complex medial and ethical issues surrounding the perioperative DNR orders are discussed, and the rationale for the recently introduced American Society of Anesthesiologists (ASA) guidelines is highlighted.
Most of the surgery performed in patients with DNR orders is palliative and designed to improve patient comfort or simplify care. For many practitioners the definition of anesthesia includes routine suppression of respiration and performance of procedures such as endotracheal intubation and volume or drug infusion, which in other settings are often refused as part of DNR orders. Most consider resuscitation, in the context of anesthesia, to be the administration of chest compressions or cardioversion . Inhaled and intravenous anesthetics can cause myocardial depression, vasodilation, and cardiac dysrhythmias. Respiratory and circulatory depression may be produced or exacerbated by opioids and sedatives. Local anesthesia with conscious sedation may reduce but not eliminate the risk of cardiac or respiratory depression. The surgical procedure itself may lead to cardiovascular or respiratory decompensation. These iatrogenic physiologic abnormalities are superimposed on patients with significant and often multiple organ system abnormalities. Thus, the patient with DNR orders undergoing a surgical procedure is likely to be at increased risk to suffer cardiac or respiratory decompensation relative to the nonoperative patient. Conversely, patients sustaining a cardiac or respiratory arrest in the perioperative period may also be more likely to suffer from transient insults (e.g., anesthetic-induced airway obstruction), that are more responsive to resuscitative efforts [8,9]. A detailed discussion with patients, including prognostic information about cardiopulmonary resuscitation will help clarify their wishes . This discussion should ideally occur at the time the DNR order is initiated, and include education about the ramifications of anesthesia.
Ethical medical decision making involves the prioritization of what are often conflicting ethical principles and practical considerations. When analyzing perioperative DNR orders, four ethical concepts are immediately important. The first principle is nonmaleficence, epitomized by the Hippocratic dictum to "first do no harm." The second concept is beneficence, or to perform a good, moral act for the patient. Third is the principle of patient autonomy, which has emerged as a predominant principle in ethical medical decision making. The fourth principle is distributive justice which allows society to provide medical resources to those best able to benefit from them. Although justice has not traditionally been invoked in our society when making individual patient decisions, it seems clear that this will change as health care policy changes. These basic principles may be competing or complementary in the various situations and institutional solutions to perioperative DNR orders. We will now evaluate four possible hospital policies for the management of perioperative DNR orders in light of these ethical principles.
A. Automatic Suspension of DNR Orders in the Perioperative Period
Automatic suspension of DNR orders during a surgical procedure and for an arbitrary period postoperatively is the most straightforward policy to invoke within a hospital. Since all patients and situations are treated alike, the institution avoids the potential of wrongful death law suits. During the perioperative period it may be impossible to distinguish between a cardiac arrest resulting from administration of a medication, performance of an invasive procedure, or from natural progression of a patient's primary disease. Nonmaleficence can be invoked to support that DNR is incompatible with surgery and anesthesia. Some practitioners consider every arrest occurring during anesthesia to be potentially reversible. However, recent data from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) suggests that patients with DNR orders who have a cardiac arrest in the operating room will not leave the hospital even if resuscitated .
Strengths of automatic suspension of DNR orders during the perioperative period (with or without patient permission) include gaining time to determine actual cause(s) of arrest, and allowing the patient the possibility of returning to baseline physiologic function after surgery. This approach also protects physicians who believe that willingly allowing a patient to die during surgery is a breach of the principle to do no harm. However, honoring the principle of patient autonomy is in conflict with a policy of automatic suspension of perioperative DNR orders. This policy effectively removes the patient from a decision-making role, even if he or she is willing to accept the risk of operative mortality. In fact, at least one hospital has been sued for negligence and battery related to the performance of cardiopulmonary resuscitation on a patient with DNR orders . Another negative aspect of this policy is that withdrawal of care (a separate issue from DNR) needs to be considered in some patients if a persistent vegetative state results from resuscitation.
B. Informed Suspension of the DNR Orders During the Perioperative Period
The principle difference under this policy is that patients with DNR orders must be informed of perioperative changes to their resuscitation status. Steps are clearly taken to inform the patient (or surrogate) of the risks of intraoperative cardiopulmonary arrest and that in the event of an arrest full resuscitative efforts would be used. Such policy risks being interpreted (by the public) as a defensive institutional posture . A positive point of this approach is that patient autonomy is better protected since patients have the option of refusing a proposed procedure and seeking care at an institution with policies more aligned with their viewpoint(s). However, if surgery cannot be performed elsewhere, the patient may be denied care unless he or she conforms to hospital policy. From a beneficence standpoint, this policy is superior to that of not informing patients as it necessitates a discussion.
C. Continuing DNR Orders Except for Airway Intervention
Some institutions honor perioperative DNR orders with the specific exception of intubation and mechanical ventilation. The rationale for this approach is that airway interventions constitute an intrinsic part of anesthesia and cannot be withheld when providing anesthetic care . Positive aspects of this approach include freedom to perform anesthesia per routine by the anesthesiologist and initiation of discussions with and education of the patient regarding differences between respiratory and cardiac arrest. Negative aspects of this policy include compromise of patient autonomy by excluding airway interventions from any perioperative limits on resuscitation. For some patients, placement of an endotracheal tube and possible reliance on mechanical ventilation in the postoperative period is the component of resuscitation most feared; many patients are explicit in this regard in advance directives. It is also possible that patients will misunderstand the policy (especially in the absence of appropriate education), leading to potential conflict between patient and clinician.
D. Continuing all DNR Orders During the Perioperative Period
Some institutions allow DNR orders to remain in effect in the perioperative period. This policy is based on informed discussions with the patient (or surrogate) which includes information regarding the risk of intraoperative cardiac or respiratory arrest tailored to the contemplated anesthetic technique. Patient preferences are determined regarding general anesthesia in the event that planned sedation or regional anesthetic fails, with time limitations discussed for intubation and mechanical ventilation. Any therapies may be withheld including chest compressions, electrical countershock, vasoactive drug therapy, endotracheal intubation, and mechanical ventilation. However, during perioperative discussions it must be made clear to patients that a planned sedation or regional anesthetic may fail, necessitating general anesthesia to complete the surgical procedure. The decision to refuse intraoperative resuscitation does not necessarily exclude maximal therapeutic efforts for complications short of complete cardiac or respiratory arrest and could conceivably allow for therapies such as opioid receptor antagonists, fluid therapy, pressors, or mask ventilation.
This policy upholds patient autonomy to the greatest degree, with the freedom from unwanted resuscitative procedures. Precedence is found in the care of terminally ill patients with DNR status on hospital wards who receive parenteral pain medications and sedatives in large doses to achieve adequate analgesia regardless of the physiologic side effects. Improved communication between clinicians and their patients results. Preoperative discussions must include education regarding the anesthetic state and establishment of an understanding of the patients' wishes within this context. Patients with DNR orders may alter those orders during the perioperative period once the unique aspects of anesthesia and surgery are explained clearly [9,13].
Weaknesses of continuing DNR orders into the perioperative period lie predominantly within the confines of the health practitioner and hospital. As mentioned above, some anesthesiologists think that withholding resuscitation in the volatile physiologic setting of anesthetic care constitutes a violation of the principle of nonmaleficence. Under these circumstances, the practitioner should have the option of transferring care of a patient to another anesthesiologist. From an institutional perspective, this policy could result in litigation, particularly if preoperative discussions did not take place, were inadequately documented, or if families did not fully understand the patient's wishes. Hence, preoperative discussions (which should include anesthesia and surgery attending doctors, as well as the primary care physician when possible) are crucial in clarification of existing DNR orders.
Policies may stipulate the suspension of DNR orders in emergencies when informed consent is impossible. A comparison can be made between the DNR patient and the Jehovah's Witness patient undergoing surgery. Institutions have adopted policies that allow the informed Jehovah's Witness to refuse transfusion and risk perioperative death. The DNR patient, like the Jehovah's Witness, has refused specific interventions. In refusing treatment neither one directly intends to die in the operating room but accepts death should it occur . Regarding the principle of distributive justice, a resuscitation policy that allows patients with DNR orders to refuse resuscitation in the perioperative period would be expected to conserve operating room and intensive care resources in a population with a limited likelihood to benefit from these procedures.
We have two recommendations. The first is that each department of anesthesiology should have a policy regarding DNR orders in the perioperative period. The second recommendation is that, of the choices we have presented, we favor continuing all DNR orders during the perioperative period after discussing this with the patient (Option D, above). Although some believe that conflicts between the ethical, medical, and practical considerations cannot be resolved, recent developments have shown that uniform policies are feasible. In October 1993 the ASA formulated their "Ethical Guidelines for the Anesthesia Care of Patients and Do Not Resuscitate Orders or Other Directives that Limit Treatment" . This policy acknowledges that automatically suspending DNR orders or other directives that limit treatment prior to procedures involving anesthetic care may not sufficiently address a patient's rights to self-determination in a responsible and ethical manner. The ASA guidelines respect an informed suspension of DNR orders during the perioperative period if explicitly discussed with the patient or surrogate. The policy allows airway management and other treatment options, or will honor perioperative DNR orders if the patient so states. Patient autonomy is upheld to the greatest degree with this approach. Professional integrity is maintained such that in cases of moral conflict "the anesthesiologist should withdraw in a nonjudgmental fashion, providing an alternative for care in a timely fashion." Distributive justice is served in that an open discussion of options, resources, and outcomes should ensue with the patient and family or proxy. The American College of Surgeons has recently adopted similar guidelines . These statements provide important groundwork from which each hospital can develop policies to address the issue of perioperative DNR orders.
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