Do-not-resuscitate orders in the OR—do they work for the patient? - Opinion

AORN Journal,  August, 2002  by Mary Roberts

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Ethics can be defined simply as doing the right thing, but the difficulty lies in discerning whose definition of the right thing should be used. Some authors maintain that ethics "is concerned with doing good and avoiding harm." (1) In the medical arena, ethics can have far reaching implications, Nurses must remember to give care according to the patient's need and not the nurse's perception of that need. Care never can be withheld or reduced because a caregiver believes the patient to be noncompliant, uneducated, or unworthy.

PATIENT AUTONOMY

Autonomy, which is one of the concepts of ethics, can be described as self-governing or the right to choose. After being accused of wrongdoing but before his trial, the Greek philosopher Socrates could have exiled himself and avoided the upcoming trial. He chose to remain in Athens, Greece, even though he knew death could be the consequence of his trial. (2) History may argue that the trial was unethical because of the unjust verdict handed down, but Socrates was satisfied because he retained his autonomy and decision making during the trial and sentencing period.

Patient autonomy also can be defined as a respect or regard for personhood. (3) This is the fundamental ethical principle guiding the advance directives movement. The purpose of informed consent is to ensure that the patient has the information necessary to make decisions that affect the care he or she receives. Advances in medical knowledge and science have allowed physicians and nurses to educate members of the public about early detection of disease, intensely manage chronic pain, and extend life beyond that which some philosophers may deem moral or ethical. With these complex courses of action comes a responsibility to ensure that patients are allowed to participate in the healing process so it works effectively. (4) Nurses are particularly influenced by the concept of autonomy because they are required to provide medical aid with respect for the patient. (5) By applying principles of equity, self-determination, and well-being, as well as autonomy, health care workers and patients can justify care decisions. (6)

THE RIGHT OF REFUSAL

The right of a patient to participate in his or her own care includes the right to refuse treatment. This leads to the dilemma of the patient having a do-not-resuscitate (DNR) order in place when entering the perioperative setting. Should a DNR be suspended when a patient who is terminally ill undergoes a palliative surgical procedure for debulking a tumor or relieving an obstruction? If the DNR order is suspended, how soon after the procedure should it be reinstated? Institutions may have a policy outlining a process for such an event, but it often is vague and inexact, leaving room for discussion and decision.

Patients are taken to the OR for a number of reasons. Some of these include debridement to aid in the healing process, repair of fractures, or relieving an obstruction and easing pain. If a patient dies in the OR, perioperative team members worry about their inability to help the individual, failure to save a life, and perhaps a future lawsuit. Should the patient or designated surrogate have the final say as to whether a DNR is continued in the surgical and postanesthesia care unit setting? Does the hospital own this liability?

One case that drew considerable attention to this matter was Cruzan v Director of Missouri Department of Health. Nancy Cruzan was left in a persistent vegetative state by an automobile accident. She was kept alive through a feeding tube, and her parents wanted the tube removed. The case was taken before the US Supreme Court, where Chief Justice William H. Rehnquist, in the prevailing ruling in 1990, maintained that although the decision to choose between life and death is deeply personal with obvious overwhelming finality, the state legitimately could continue to protect the life of Cruzan. Justice William J. Brennan, Jr, in his dissenting statement said that the patient "is entitled to choose to die with dignity." (7) Therein lies an ethical dilemma. Who is right and who is wrong?

In years past, it was understood that a DNR was suspended automatically when a patient entered the OR. Patients and their family members had little if any choice in deciding when to suspend and reinstate a DNR. Patients today, however, demand more decision-making ability about the care given to them, as well as greater accountability from health care providers. Information on detecting symptoms of early disease and available treatments is accessible readily through the present day media. Patients are more informed than ever before. They are asking more questions and seeking to contribute to their care. Current health care providers must respond intrepidly to this entreaty. In Texas, as well as many other states, today's standard of care includes a natural death act (ie, the Texas Natural Death Act). This act helps patients understand and complete advance directives before problems arise. (8)