‘Do not attempt resuscitation’ orders in the peri‐operative period

It is increasingly common for patients to be scheduled for anaesthesia and surgery with a pre-existing ‘Do Not Attempt Resuscitation’ (DNAR) order in place. While this often applies to elderly patients, it may also apply to younger patients or even children with terminal illness [1]. Guidelines from the American Society of Anesthesiologists (ASA) have existed to assist in the management of this ethical and clinical dilemma since 1993 [2], but none have been published in the UK to date. A review of the basic ethical principles involved is needed to decide how individual anaesthetists and anaesthetic departments in the UK should manage this situation. Advance directives, such as DNAR orders, have arisen from the need for greater respect for patients' autonomy. The paternalistic attitude for which the medical profession may have been criticised in the past has gradually been replaced with a situation in which doctors and patients are partners in health. Autonomy forms one of the four principles of biomedical ethics proposed by Beauchamp and Childress [3] and refers to respect for the decision-making capacities of individuals, enabling them to make informed choices about their healthcare. This normally takes precedence over the other three principles which are beneficence (overall benefit to the patient), non maleficence (avoiding the causation of harm) and justice (fair distribution of benefits to all patients). Unfortunately, when applied to an ethical dilemma, the four principles often conflict with each other and so they only provide a framework for discussion. The paternalistic primary ethical principle of the past, namely immediate benefit to the patient, is now in competition with other conflicting principles. Furthermore, a review of the ethics surrounding DNAR orders has been necessary as a result of the implementation of the Human Rights Act 1998 on 2nd October 2000, which incorporated most of the European Convention on Human Rights into UK law. A Joint Statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing in February 2001 highlighted the articles in the Convention that are of particular importance when considering DNAR orders [4]. These include the right to life (Article 2), to freedom from inhuman or degrading treatment (Article 3), to respect for privacy and family life (Article 8), to freedom of expression, which includes the right to hold opinions and to receive information (Article 10) and to be free from discriminatory practices, such as ageism, in respect of these rights (Article 14). The spirit of the Act, which aims to promote human dignity and transparent decision-making, is reflected in the Joint Statement. A wider review of the implications of the Human Rights Act in anaesthesia and intensive care was published by White and Baldwin in 2002 [5], but this did not address the issue of DNAR orders in the peri-operative period. How then should we manage patients presenting for anaesthesia and surgery with a DNAR order in place? Before even approaching the dilemma, we must deal with the definition and understanding of the terms involved. DNAR orders are instituted on the assumption that cardiopulmonary arrest will be a spontaneous event that is the culmination of the dying process in a patient who has a terminal illness or a poor quality of life. These orders arose out of the realisation that resuscitation, including cardiopulmonary resuscitation (CPR), the process of artificial respiration and external chest compression, in such cases is inappropriate, has a poor outcome and is against the wishes of patients and family. The Joint Statement makes it clear that all DNAR orders should be discussed with competent patients, unless they indicate they do not want to do this. Unfortunately many patients in whom DNAR orders are considered are incompetent and there are no advance directives to follow. In such cases, the Joint Statement says ‘people close to the patient should be kept informed about the patient’s health and be involved in decision-making in order to reflect the patient's views and preferences.' The Mental Capacity Act 2005, due to come into force in April 2007, will bring the situation in England and Wales into line with what already exists in Scotland, where Lasting Powers of Attorney for healthcare decisions may be granted to a person by a competent patient who predicts their own future incompetence. These proxy decision-makers should be consulted regarding DNAR orders if the patient is deemed to be incompetent. The Mental Capacity Act will also give formal legal recognition to advance decisions and so codify the common law position that has already developed in this area, and which continues to operate in Northern Ireland. White and Baldwin have recently reviewed the implications of the Mental Capacity Act in the practice of anaesthesia and intensive care [6]. A recent editorial in the British Medical Journal, in relation to the Mental Capacity Act, has highlighted the implications for all doctors treating non-competent patients [7]. It must be remembered that neither relatives nor proxy decision-makers can demand treatment which is judged in medical opinion to be against the patient's interests. Although much less common, DNAR decisions may arise in children, but usually agreement will be reached about whether CPR should be attempted if the patient suffers respiratory or cardiac arrest. If disagreement persists despite attempts to reach agreement, legal advice should be sought. Parents cannot require doctors to provide treatment contrary to their professional judgement, but doctors will try to accommodate parents' wishes as far as is compatible with protecting the child's interests. Having established a DNAR order, the situation may then arise when anaesthesia is required for operative interventions that are considered appropriate. These might include provision of a support device (e.g. a feeding tube), urgent surgery for a condition unrelated to the underlying chronic problem (e.g. acute appendicitis), urgent surgery for a condition related to the underlying chronic problem but not believed to be a terminal event (e.g. bowel obstruction), a procedure to decrease pain (e.g. repair of fractured neck of femur) or a procedure to provide vascular access. When anaesthesia is considered for a patient with a current DNAR order, the patient and the anaesthetist face two additional dilemmas. Firstly, anaesthesia itself, whether regional or general, will promote cardiorespiratory instability that will require support. Second, many of the routine interventions used in giving an anaesthetic may be classified as resuscitative measures. These include the insertion of an intravenous cannula, administration of intravenous fluids, insertion of an artificial airway, delivery of oxygen, provision of respiratory assistance, cardiac monitoring and administration of vasopressor and other resuscitative drugs. The surgical procedure itself may also require resuscitative measures to be implemented. It is not difficult to see the dilemma facing the anaesthetist, and surgeon, who are involved in the care of a patient who has a written record in their notes of a wish not to receive any of these resuscitative measures, even though they are likely to be needed as a natural consequence of providing anaesthesia and surgery. If the anaesthetist were to proceed and strictly obey the general understanding of a DNAR order under such circumstances, it could possibly be construed as an act of euthanasia or assisted suicide. Surgery and anaesthesia therefore constitute a change in the patient's medical status because they introduce additional risks to the patient. Conversely, the success rates for survival following cardiac arrest in the operating theatre are significantly greater than in the general ward setting. Survival rates following anaesthetic related cardiorespiratory arrest can be as high as 92%[8]. This compares with survival rates of around 14% after other in-hospital cardiopulmonary arrests [9]. This therefore alters the likelihood that CPR in the peri-operative period will be successful and so can impact upon the original presumption on which the DNAR order was made. In the case of a DNAR order existing as a result of an advance directive, the Mental Capacity Act incorporates the current situation under common law whereby refusals of treatment by adults are held to be legally binding if the decision is intended to apply in the circumstances that subsequently arise [6]. It is clear that the situation of anaesthesia for an operative procedure that is considered appropriate is unlikely to have been specifically considered when the advance directive was originally made. The anaesthetist's ethical principles of beneficence and non maleficence during anaesthesia for an appropriate operative procedure on a patient with an existing DNAR order would tend to lead them to preserve the patient's life and thus perform resuscitative measures and even CPR if required. Although this may not strictly be in breach of the Mental Capacity Act due to the unique circumstances that may not have been considered when the DNAR order was made, it may be in breach of Article 3 (prohibition of torture or of inhuman or degrading treatment) of the Human Rights Act if the resuscitation was shown not to be in the best interests of the patient. In North America, prior to the publication of the ASA guidelines in 1993, DNAR orders were routinely suspended prior to surgery to enable anaesthetists to follow their ethical principles as described. During two recent seminars on ‘Advances in the peri-operative management of patients with fractured neck of femur’ at the Association of Anaesthetists in London, opinion was sought on current UK practice. Routine suspension of DNAR orders prior to anaesthesia and surgery was the majority view of the audience on both occasions and this probably represents the commonest way of dealing with this situation currently in the UK. There are no guidelines that we are aware of to suggest otherwise and the situation is not addressed by the Joint Statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing [4]. However, the ASA guidelines state that automatically suspending a DNAR order in the operating theatre ‘may not sufficiently address a patient’s rights to self-determination in a responsible and ethical manner' [2], and similar sentiments have been expressed by the American College of Surgeons [10] and the Canadian Anaesthesiologists' Society Committee on Ethics in 2002 [11]. The resolution of this conflict between the ethical position of the anaesthetist and the patient can only be resolved by open, detailed and frequent communication with the patient or relatives in a manner of transparency now enforced by the Human Rights Act and the Mental Capacity Act. In a review of this subject, Tungpalan and Tan [12] agree that the DNAR order should not be automatically suspended but that there should be only one alternative to DNAR in the operating room, and that is full resuscitation. Another review by Waisel et al. [13] suggests three main categories of resuscitation – full resuscitation, goal directed resuscitation and procedure directed resuscitation [13]. The goal directed option involves judgement of the anaesthetist and surgeon in dictating how far and what resuscitative measures should be employed taking into account the patient's expressed values and goals, such as not wanting to be considered for respiratory support in an intensive care unit. The procedure directed option allows the patient some degree of autonomy in being able to select certain resuscitative procedures, such as the use of oxygen therapy and vasopressor drugs but without, for example, the use of external cardiac massage or defibrillation. However, it must also be appreciated that some procedures are essential to providing anaesthetic care (such as airway management and intravenous fluids as described above). Refusal of these procedures would be inconsistent with a request for anaesthesia and surgery. The Cleveland Clinic have published an on-line patient information sheet giving this three-option approach, as outlined in the ASA guidelines [14]. It is surprising that no guidelines or serious discussions on this matter have appeared in the UK to parallel the developments in North America. It is our view that DNAR orders should not automatically be suspended for surgery and anaesthesia. There must be close discussion between anaesthetists, surgeons and physicians or paediatricians within operating teams and implementation of local policies including consultation with patients, parents, relatives or proxy decision-makers before surgery. This should be included in the process of obtaining informed consent for surgery and anaesthesia and the discussion should be recorded in the patient's notes. General policies cannot be made to apply to individual situations, but there should be a policy to review each DNAR order in advance of surgery and anaesthesia with the adoption of a goal orientated or procedure related approach. Decisions also need to be taken as to when the original DNAR order is reinstated following surgery and anaesthesia. Suggestions as to when this should be have included: on discharge from the recovery area [2], following the post anaesthetic visit, when the patient has been weaned from mechanical ventilation, or when the medical team and the relatives agree to reinstate the DNAR order [1]. For incompetent patients, views should be sought from relatives or proxy decision-makers to reflect the patient's views and preferences, but it must be remembered that relatives, parents or proxy decision-makers cannot demand treatment that is judged to be against the patient's interests. If anaesthetists find themselves unable to proceed because of their own moral views they must ensure an alternative for care to be continued without undue delay. In an emergency situation, resuscitation including CPR should be attempted unless the patient has refused CPR, the patient is clearly in the terminal phase of illness, or the burdens of the treatment outweigh the benefits [4], i.e. attempt resuscitation unless it is clearly in the patient's best interests not to do so. However, it is increasingly recognised that inappropriate resuscitation is inconsistent with good medical practice and indicates poor decision-making. Conroy et al. have recently suggested that universal resuscitation for all residents in care homes and community hospitals should perhaps not be the default position due to the poor outcomes obtained [15]. It is no longer acceptable for anaesthetists to automatically seek to suspend DNAR orders prior to anaesthesia. The European Convention on Human Rights is now enshrined in UK law and the Mental Capacity Act is expected to come into force on 1 April 2007. If we are not to face litigation in the future we must read, understand and implement what the law requires from us in this area. The paternalistic primary ethical principle of the past, namely immediate medical benefit to the patient, has been overtaken. Anaesthetic departments and the Association of Anaesthetists of Great Britain and Ireland should develop guidelines for local and UK anaesthetists, respectively, similar to those produced by the ASA, for the peri-operative management of patients with a DNAR order in place. Individual anaesthetists must use the time now allocated within their contracts for pre-operative assessment to give these cases the time and attention they demand.

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