Section 1: Palliative Care
Palliative Surgery in the Do-Not-Resuscitate Patient: Ethics and Practical Suggestions for Management

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Case

A 79-year-old woman with stage IV metastatic non–small cell lung cancer on hospice presents with increased hip pain. Her primary oncologist images the hip, and an impending hip fracture secondary to metastatic disease is diagnosed. She is offered an open reduction and internal fixation of her hip in the hopes of restoring some limited mobility and to provide pain relief at the end of her life so that she may attend her granddaughter’s wedding. She is adamant that she not be resuscitated in the

History of DNR orders in the perioperative period

Cardiopulmonary resuscitation (CPR) is the only medical intervention for which no consent is required, and an explicit physician’s order is necessary for it to be withheld. Originally described as treatment for intraoperative cardiac arrest, its use has become widespread outside the OR and outside the hospital. Whereas mortality for intraoperative cardiac arrest was relatively low (∼50%), survival figures for out-of-OR cardiac arrest were worse (10%–30%).7, 8

Through the 1960s and 1970s as the

Hospice patients

There is a common misunderstanding that patients who have enrolled in hospice also have given up the desire for resuscitation. Designating oneself as DNR is not necessary for hospice care. Only 2 requirements must be met for someone to be eligible for hospice: (a) the patient, or designated surrogate, expressly desires to focus on comfort and quality of life, while forgoing curative therapies for the primary, life-threatening disease; and (b) a physician certifies that the patient has a life

Suggested practical approach to the preoperative evaluation of the DNR patient presenting for surgery

  • Uniform policies suspending DNR orders before surgery are inappropriate and are not useful.

  • It is essential and required that a discussion with the patient regarding values and goals take place and that those values and goals be discussed in the context of the specific procedure and anesthesia required.

    • This discussion should be undertaken by the attending physician and not delegated.

    • If resuscitation is to be limited, the patient may choose to appoint the anesthesiologist or surgeon as a

Intraoperative and postoperative symptom management

The anesthesiologist is in a unique position to alleviate suffering. Focus should be not only on providing adequate analgesia but also on other common symptoms more common in the palliative care population: dyspnea, cough, sedation, anxiety, and nausea. In addition, the DNR patient may be older, sicker, and require larger doses of opioids, increasing the risk of postoperative delirium.18 Appropriate treatment of symptoms while minimizing the risk of complications is, of course, precisely the

Summary

Whereas palliative care in the United States was in its relative infancy just a decade ago, it has made tremendous strides in the intervening years. The central tenets of providing symptom management and comfort for all patients, no matter what the stage of their illness, and to address goals of care and personal values in the context of the patient-family unit, are widespread now. These tenets are consistent with the burgeoning movement toward patient- and family-centered care, away from

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References (30)

  • J. Gavrin

    Anesthesiology and palliative care

    Anesthesiol Clin North Am

    (1999)
  • C. Deasy et al.

    Cardiac arrest outcomes before and after the 2005 resuscitation guidelines implementation: evidence of improvement?

    Resuscitation

    (2011)
  • J. La Puma et al.

    Life-sustaining treatment. A prospective study of patients with DNR orders in a teaching hospital

    Arch Intern Med

    (1988)
  • M. Ewanchuk et al.

    Perioperative do-not-resuscitate orders—doing ‘nothing’ when ‘something’ can be done

    Crit Care

    (2006)
  • American Society of Anesthesiologists. Ethical guidelines for the anesthesia care of patients with do-not-resuscitate...
  • American College of Surgeons

    Statement on advance directives by patients: “Do not resuscitate” in the operating room

    Bull Am Coll Surg

    (1994)
  • American Association of Perioperative Nurses (AORN). Perioperative care of patients with do-not-resuscitate or...
  • J. Sprung et al.

    Predictors of survival following cardiac arrest in patients undergoing noncardiac surgery: a study of 518,294 patients at a tertiary referral center

    Anesthesiology

    (2003)
  • President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forego life-sustaining treatment: ethical, medical, and legal issues in treatment decisions

    (1983)
  • M.V. Clemency et al.

    “Do not resuscitate” (DNR) orders in the perioperative period—a comparison of the perspectives of anesthesiologists, internists, and surgeons

    Anesth Analg

    (1994)
  • C.B. Cohen et al.

    Do-not-resuscitate orders in the operating room

    N Engl J Med

    (1991)
  • R.D. Truog

    “Do-not-resuscitate” orders during anesthesia and surgery

    Anesthesiology

    (1991)
  • R.M. Walker

    DNR in the OR. resuscitation as an operative risk

    JAMA

    (1991)
  • R.L. Martin et al.

    Ethical issues in anesthesia: management of the do-not-resuscitate patient

    Anesth Analg

    (1991)
  • Panetta L. Omnibus budget reconciliation act of 1990. United States House of Representatives....
  • Cited by (22)

    • Adult Perianesthesia Do Not Resuscitate Orders: A Systematic Review

      2019, Journal of Perianesthesia Nursing
      Citation Excerpt :

      The human and provider dimension is epitomized by a series of articles examining how anesthesia providers, surgeons, perioperative nurses, internal medicine physicians, and patients view the use of perianesthesia DNR orders. Significantly, only three studies focus on how perianesthesia patients feel about using their DNR orders during anesthesia.32,51,60 The remaining articles grouped within the human and provider dimension focus on how anesthesiologists, CRNAs, surgeons, and internists experience perianesthesia DNR orders.

    • The Challenge of Perioperative Advance Care Planning

      2019, Journal of Pain and Symptom Management
      Citation Excerpt :

      The impact of an incomplete understanding of routine anesthetic practice is a common problem faced by anesthetists when interpreting AHD and NFR orders as they will often not have been ratified with the future possibility of surgery in mind.18 Knipe and Scott describe that NFR orders were routinely suspended in the intraoperative period by anesthetists for reasons such as concern that cardiac arrest can be caused iatrogenically and swift management can produce good outcomes; the belief that everything should be done to ensure patient survival in theater; and the impression of significant overlap between routine anesthetic interventions and aspects of CPR.17,19 In a recent survey of Australian anesthetists, 45.7% reported to “always” following an NFR order, with others reporting they “often,” “sometimes,” and “didn't” adhere to such orders.12

    • Do-Not-Resuscitate Orders in the Perioperative Environment: A Multidisciplinary Quality Improvement Project

      2017, AORN Journal
      Citation Excerpt :

      This conversation and reevaluation should be a standard component of care. The risks, benefits, implications, and potential outcomes of anesthesia and surgery in relation to the DNR order must be discussed with the patient before initiating anesthesia and surgery.3,7,17-21,23 Nurses are competent and capable of initiating the discussion about DNR orders before surgery, and this is within the scope of nursing practice.24,25

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