Abstract

In our fragmented health care system, effective communication between “leadership dyads,” such as anesthesiologists and surgeons, is instrumental in safeguarding surgical patient outcomes and quality of care. This paper investigates the ethical issues confronting care providers as they deliberate on the implementation of DNAR orders in the preoperative setting. In light of mounting evidence that surgical patients with active DNAR orders have higher mortality and postoperative complication rates than non-DNAR patients, this paper argues against the automatic suspension of DNAR orders and in favor of contiguous communication between the anesthesiologist, surgeon, and the patient regarding the status of a pre-existing DNAR order in one group setting. We maintain Cohen and Cohen’s required reconsideration policy and argue that a coordinated preoperative discussion is essential for reducing postoperative complications and mortality rates. Finally, challenges to the implementation of required reconsideration in one group setting are addressed.

Introduction

The Do-not-attempt-resuscitate (DNAR) order is an advance directive that provides health care providers with instructions on navigating patient preferences regarding life-sustaining interventions in the event of a cardiopulmonary arrest. [1], [2] In response to the public’s concerns regarding paternalistic medical decision-making, the Patient Self-Determination Act (PSDA) extended the informed consent doctrine to advance directives like DNAR orders as a means for allowing patients the autonomy to make choices about their own medical care. [3], [4], [5] The PSDA not only required that patients be adequately informed of the risks and benefits inherent in medical procedures, but it also stipulated the legal requirement to protect patients’ rights to refuse medical treatment. [5]

Currently, United States’ hospitals that are accredited by The Joint Commission are required to have DNAR policies in place. [1], [6] Though only about 15 percent of patients with pre-existing DNAR orders will undergo surgery, [7] these patients are subject to variable policies across the country; some policies automatically suspend DNAR orders during the perioperative period, [8] while others require preoperative discussions between care providers and the patient in order to identify a plan that conforms to the patient’s goals of care. [9] 

A DNAR order does not express a patient’s wish to die. A patient with a DNAR order may want surgery to extend life or improve the quality of life. For example, a patient with a terminal illness who develops a bowel obstruction may consider the benefits of palliative surgery to outweigh the risks.  [9], [10], [11], [12] If a cardiopulmonary arrest were to occur during surgery, it could be reversed without permanent damage. [10] Such reasoning guides the decision-making of care providers as they deliberate on pursuing procedure-directed DNAR orders as opposed to goal-directed approaches. [11] By focusing on individual procedures, the former approach provides precision and clarity on permissible procedures in the event of a cardiopulmonary arrest whereas the latter focuses broadly on the patient’s end goals, preferences, and values. Although some care providers may prefer procedure-directed DNAR orders due to the ambiguity inherent in goal-directed approaches, [10], [11]they are nonetheless obliged to prioritize patient interests over their own. [13]

The controversy over suspending DNAR orders during the perioperative setting is rooted in the fact that anesthesia is an inextricable component of surgery. [1], [14] The administration of anesthetics may lead to hemodynamic instability and respiratory depression, [5], [10] resulting in a cardiopulmonary arrest that could be reversed by securing the airway, administering anti-arrhythmics, or initiating cardiopulmonary resuscitation. [5], [9]In fact, anesthetic manipulations involving mechanical ventilation, intubation, paralytic or vasoactive agents constitute resuscitative measures in different contexts. [10], [14] Thus, the full benefits conferred by surgery cannot be reasonably achieved without administering certain resuscitative interventions. [15] This rationale has been used to justify automatic suspension of DNAR orders in the perioperative setting. As Truog et al. and Micco et al. recognize, many anesthesiologists consider it inappropriate for a “patient to die as a direct result of an anesthetic complication” [16] due to fear of malpractice litigation or psychological consternation over having their “hands tied” by an active DNAR order. [17]

The issue is further complicated by evidence suggesting that patients with DNAR orders are at an increased risk of developing major postoperative complications and mortality compared to non-DNAR patients. [18], [19], [20], [21], [22] Wenger et al. demonstrated that hospitalized patients who have a DNAR order are subject to an increased rate of in-hospital mortality despite adjusting for sickness, patient, and hospital characteristics. [18] Similarly, in a study involving data from the National Surgery Quality Improvement Program (NSQIP) Database, Kazaure et al. reported that patients with DNAR orders experience a “short-term mortality rate of 17 percent that is triple the rate for [patients] without DNAR orders.” [9], [19] These data are corroborated by other studies, such as those conducted by Brovman et al. [20] and Walsh et al, [21] indicating that pre-existing DNAR status is an independent predictor of mortality. While the reasons for this phenomenon are unclear, it is speculated that the DNAR order is a marker for severe comorbidities that renders it unlikely for a patient to recover from surgery. There is some evidence in the literature that suggests that the presence of a DNAR order compromises the quality of care given to patients with DNAR orders; Aziz et al. and Mirachi et al. suggest that care providers may misconstrue DNAR orders for the patient opting for less aggressive care throughout the duration of their illness. [23], [24] Thus, there is an urgent need for care providers to carefully reevaluate DNAR orders preoperatively and discuss in length with the patient and his or her family postoperative expectations and risks.

Required Reconsideration in a Group Setting

That said, a number of professional organizations, such as American College of Surgeons and American Society of Anesthesiologists, oppose automatic suspension of DNAR orders in favor of the “required reconsideration” policy. [5], [25], [26]First proposed by Cohen and Cohen, [27] “required reconsideration” challenges automatic suspension on the grounds that it violates the patient’s autonomy and self-determination. Cohen and Cohen’s recommendation imposes a responsibility on the anesthesiologist and surgeon for obtaining documentation and providing a rationale for DNAR suspension. It also requires the anesthesiologist and surgeon to provide information about different resuscitative measures and elicit the patient’s thoughts on the types of medical interventions they would accept in the event of a cardiac arrest.

One crucial step is, however, omitted in Cohen and Cohen’s approach. It is recommended that the preoperative discussion be a group discussion involving the anesthesiologist, surgeon, and patient or surrogate. Such a multispecialty preoperative discussion with all parties present would allow the physicians to disclose the inherent risks and benefits of surgery and anesthesia and elicit the patient’s specific preferences in one group setting, thereby minimizing the risk of possible miscommunication. Notably, “required reconsideration” in a group discussion could serve as the impetus for a more integrated approach to health care delivery in the preoperative period, a set-up that is currently infrequently seen. Group preoperative discussions could enable the anesthesiologist and surgeon to clarify the meaning of the term “resuscitation,” which may be ambiguous in the context of anesthetic care. We maintain that such a coordinated discussion would promote trust and reduce the risk of misunderstandings and wrongful death law suites.

This approach could also address existing inconsistencies in preoperative re-evaluation of DNAR orders by both anesthesiologists and surgeons. In their simulation-based study, Waisel et al. discovered that only 57 percent of anesthesiologists addressed resuscitation with their patients in the perioperative window. [28] Clemency and Thompson reported that 60 percent of anesthesiologists surveyed in their study were more likely than surgeons to automatically assume DNAR suspension in the operating room without discussing it with the patient. [29] In contrast, a more recent study conducted by Burkle et al. demonstrated that “anesthesiologists (18 percent) are significantly less likely to suspend DNR orders than surgeons (38 percent) or internists (34 percent).” [30] These studies provide evidence for conflicting approaches to DNAR suspension between anesthesiologists and surgeons, rendering care for patients with pre-existing DNAR orders ambiguous and inconsistent. Thus, having a group discussion involving care providers from both the surgical and anesthetic specialties would increase accountability to provide cohesive, consistent, and non-contradictory information to the patient. In emergent scenarios, where it is impractical to schedule a preoperative discussion with the patient or surrogate, the surgeon and anesthesiologist should at least reach a consensus on the most appropriate course of action.

Challenges to Effectively Implementing Required Reconsideration in One Group Setting

Implementing required reconsideration in one group setting is contingent upon addressing two structural constraints. Firstly, due to the fragmented nature of our health care system, preoperative discussions concerning surgical and anesthetic interventions are routinely conducted separately with the anesthesiologist, surgeon, and members of the palliative care team. Neither the anesthesiologist nor the surgeon possesses comprehensive knowledge of the patient’s medical history and must therefore rely on the patient’s primary care provider and the palliative care team to provide missing information. This may especially hold true for patients in intensive care. [11]This fragmented knowledge of the patient’s medical history, coupled with the physicians’ limited time and competing priorities, render it difficult for them to arrive at similar conclusions regarding the patient’s life circumstances and preferences, both of which are important for understanding the rationale of the DNAR order and for creating a postoperative treatment plan.

Secondly, effective communication between the anesthesiologist and surgeon is hindered by “divergent socializations in their specialties,” [31] differing value systems, and negative perceptions each specialty has of the other. [32] Goyal notes that the root of communication breakdown between the two specialties lies in a “natural reluctance to interrupt, fear of embarrassment or outright retribution, concern about being misjudged, or simply not knowing what to say or how to say it.” [33] Lingard et al. found that communication breakdown occurred in 30 percent of team exchanges in the operating room. He speculated that these communication breakdowns can be classified into several categories: “occasion” failures due to poor timing, “purpose” failures due to unresolved issues, “content” failures due to inaccurate information, and “audience” failures due to excluding key intraoperative personnel from discussions. [34] Communication breakdowns between anesthesiologists and surgeons can contribute to misunderstandings, medical errors, and the use of misleading medical jargon. If required reconsideration is to successfully be implemented in a group setting, it is imperative to address these two challenges.

Conclusion

In conclusion, Cohen and Cohen’s recommendation for required reconsideration of DNAR advance directives can be enhanced if institution-wide policies recommended surgeons and anesthesiologists to engage in a preoperative discussion with the patient or surrogate in one group setting. Given the evidence indicating an association between intraoperative retention of DNAR status and increased mortality and postoperative complications, required reconsideration could enable the surgeon and anesthesiologist to clearly communicate the risks inherent in sustaining a DNAR order intraoperatively. It would create accountability on the part of both care providers to understand the patient’s own preferences and goals of care. Prior to this discussion, it is encouraged for the surgeon and anesthesiologist to consult with the patient’s primary care and/or palliative care providers to elicit the information that they have about the patient’s condition and prognosis. This communication is critically important for developing a holistic, integrated, and patient-centered approach when one is considering surgery for a patient with a pre-existing DNAR order.

Reference List

[1] Sumrall, William D., Elizabeth Mahanna, Vivek Sabharwal, and Thomas Marshall. "Do Not Resuscitate, Anesthesia, and Perioperative Care: A Not So Clear Order." Ochsner Journal 16, no. 2 (2016): 176–179.

[2] Breault, Joseph L. "DNR, DNAR, or AND? Is language important?" Ochsner Journal 11, no. 4 (2011): 302–306.

[3] U.S. Congress. House. Patient Self-Determination Act of 1990. HR 4449. 101st Cong, 2nd Sess. Introduced in House April 3, 1990. https://www.congress.gov/bill/101st-congress/house-bill/4449. 

[4] Rothenberg, David M. "Informed refusal—DNR orders in the patient undergoing anesthesia and surgery and at the end-of-life." In Clinical Ethics in Anesthesiology: A Case-Based Textbook, eds. Gail A. Van Norman, Stanley H. Rosenbaum, and Stephen Jackson (Cambridge, UK: Cambridge University Press, 2011): 13-18.

[5] Jackson, Stephen. "Perioperative do-not-resuscitate orders". AMA Journal of Ethics 17, no. 3 (2015): 229–235. https://doi.org/10.1001/journalofethics.2015.17.3.nlit1-1503.

[6] The Joint Commission. "Patient rights." In: Manual of the Joint Commission on Accreditation of Health Care Organizations (Chicago, IL: The Joint Commission, 1994).

[7] Ewanchuk, Mark and Peter G. Brindley. "Perioperative do-not-resuscitate orders—doing ‘nothing’ when ‘something’ can be done." Critical Care 10, no. 4 (2006): 219. https://doi.org/10.1186/cc4929.

[8] Truog, Robert D.,  David B. Waisel, Jeffrey P. Burns. "Do-not-resuscitate orders in the surgical setting." Lancet 365, no. 9461 (2005): 733–735. https://doi.org/10.1016/S0140-6736(05)17999-9.

[9] McCoy, Kelly L. and Sally E. Carty. “Surgery and do-not-resuscitate orders: the real risks defined. Comment on 'High mortality in surgical patients with do-not-resuscitate orders.'” The Archives of Surgery 146, no. 8 (2011): 928–929. https://doi.org/10.1001/archsurg.2011.177.

[10] Fallat, Mary E. and Courtney Hardy. "Interpretation of Do Not Attempt Resuscitation Orders for Children Requiring Anesthesia and Surgery." Pediatrics 2018;141, no. 5 (2018). https://doi.org/ttps://doi.org/10.1542/peds.2018-0598.

[11] Truog, Robert D., David B. Waisel, and Jeffrey P. Burns. "DNR in the OR: A Goal-directed Approach." Anesthesiology 90, no. 1 (1999): 289-295. https://doi.org/10.1097/00000542-199901000-00034.

[12] Younger, Stuart J., Helmut F. Cascorbi, and Jerry M. Shuck. "DNR in the operating room: not really a paradox." JAMA 1991;266, no. 17 (1991): 2433-2434. https://doi.org/10.1001/jama.1991.03470170121036.

[13] Jackson, Stephen H., Perry Fine, Susan Palmer, Stanley Rosenbaum, Robert D. Truog, Gail Van Norman. “Response to 'Ethical Concerns in Anesthetic Care for Patients with Do-not-resuscitate Orders.'” Anesthesiology 87, no. 1 (1997): 176-178. https://doi.org/10.1097/00000542-199707000-00030.

[14] American College of Surgeons. Statement on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room. American College of Surgeons (Chicago, IL) 2014. 

[15] Rhodes, Rosamond. "An Alternate Opinion: Do-Not-Resuscitate Orders in the Operating Room." The Mount Sinai Journal of Medicine 61, no. 6 (1994): 498-499.

[16] Truog, Robert D. “Do not resuscitate” orders during anesthesia and surgery." Anesthesiology 74, no. 3 (1991): 606-608.

[17] Micco, Guy. "Do Not Resuscitate Orders in the Operating Room: The Birth of a Policy." Cambridge Quarterly of Healthcare Ethics 4, no. 1 (1995): 103-110. https://doi.org/10.1017/S0963180100005739.

[18] Wenger, Neil S., Marjorie L. Pearson, Katherine A. Desmond, Robert H. Brook, Katherine L. Kahn. "Outcomes of patients with do-not-resuscitate orders: toward an understanding of what do-not-resuscitate orders mean and how they affect patients." Arch Intern Med. 155, no. 19 (1995): 2063-20687575065. https://doi.org/10.1001/archinte.1995.00430190049007.

[19] Kazaure, Hadiza, Sanziana Roman, Julie A. Sosa. "High mortality in surgical patients with do-not-resuscitate orders: analysis of 8256 patients." Archives of Surgery 46, no. 8 (2011): 922-928. https://doi.org/10.1001/archsurg.2011.69.

[20] Brovman, Ethan Y., Andrew J. Pisansky, Anair Beverly, Angela M. Bader, and Richard D. Urman. "Do-Not-Resuscitate status as an independent risk factor for patients undergoing surgery for hip fracture." World Journal of Orthopedics 8, no. 12 (2017): 902–912. https://doi.org/10.5312/wjo.v8.i12.902.

[21] Walsh, Elisa C., Ethan Y. Brovman, Angela M. Bader, Richard D. Urman. "Do-Not-Resuscitate Status Is Associated With Increased Mortality But Not Morbidity." Anesthesia & Analgesia 125, no. 5 (2017): 1484–1493. https://doi.org/10.1213/ANE.0000000000001904.

[22] Association of periOperative Registered Nurses. AORN position statement: Perioperative care of patients with Do-Not-Resuscitate or Allow-Natural-Death Orders. Association of periOperative Registered Nurses. 2009. 

[23] Aziz, Hassan, Bernardino C. Branco, Jonathan Braun, John D. Hughes, Kay R. Goshima, Magdiel Trinidad-Hernandez, Glenn Hunter, Joseph L. Mills, Sr. "The influence of do-not-resuscitate status on the outcomes of patients undergoing emergency vascular operations." Journal of Vascular Surgery 61, no. 6 (2015): 1538-42. https://doi.org/10.1016/j.jvs.2014.11.087.

[24] Mirachi, Ferdinando L., Erin Costello, Justin Puller, Timothy Cooney, Nathan Kottkamp. "TRIAD III: nationwide assessment of living wills and do not resuscitate orders." Journal of Emergency Medicine 42 (2012): 511-20. https://doi.org/10.1016/j.jemermed.2011.07.015.

[25] American Society of Anesthesiologists. Ethical guidelines for the anesthesia care of patients with Do-Not-Resuscitate orders or other directives that limit treatment. American Society of Anesthesiologists. 2008. 

[26] American College of Surgeons. "Statement of the American College of Surgeons on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room." Bull Am Coll of Surg. 79, no. 9 (1994): 29.

[27] Cohen, Cynthia B. and Peter J. Cohen. "Required reconsideration of “Do-not-resuscitate” orders in the operating room and certain other treatment settings." Law Med Health Care 20, no. 4 (1992): 354-363. https://doi.org/10.1111/j.1748-720x.1992.tb01216.x.

[28] Waisel, David, Robert Simon, Robert Truog, Hemanth Baboolal, Daniel B. Raemer. "Anesthesiologist Management of Perioperative Do-Not-Resuscitate Orders: A Simulation-Based Experiment." Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare 4, no. 2 (2009): 70-76. https://doi.org/10.1097/SIH.0b013e31819e137b.

[29] Clemency, Mary V. and Nancy J. Thompson. “'Do not resuscitate' (DNR) Orders in the Perioperative Period—A Comparison of the Perspectives of Anesthesiologists, Internists, and Surgeons.” Anesthesia & Analgesia 78, no. 4 (1994): 651-658. https://doi.org/10.1213/00000539-199404000-00006.

[30] Burkle, Christopher M., Paul S. Mueller, Keith M. Swetz, C. Christopher Hook, and Mark T. Keegan. "Physician perspectives and compliance with patient advance directives: the role external factors play on physician decision making." BMC Med Ethics 13, no. 31 (2012). https://doi.org/10.1186/1472-6939-13-31.

[31] Lynn, Joanne. “"When I Use a Word," with Respect for Lewis Carroll.” Cambridge Quarterly of Healthcare Ethics 28, no. 3 (2019): 410–412. https://doi.org/10.1017/S0963180119000318.

[32] Cooper, Jeffrey B. "Critical Role of the Surgeon–Anesthesiologist Relationship for Patient Safety." Anesthesiology 129, no. 3 (2018): 402-405. https://doi.org/10.1097/ALN.0000000000002324.

[33] Goyal, Rakhee. "Surgeons and Anesthesiologists: Need to Communicate?" Journal of Anaesthesiology and Clinical Pharmacology 29 (2013): 297-8. https://doi.org/10.4103/0970-9185.117040.

[34] Lingard, Lorelei, Sherry Espin, Shona Whyte, Glenn Regehr, G. Ross Baker, Richard Reznick, Jordan Bohnen, Diane M. Doran, and Ellen Grober. "Communication failures in the operating room: an observational classification of recurrent types and effects." Qual Saf Health Care 13 (2004): 330-334. https://doi.org/10.1136/qshc.2003.008425.