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Health Care Industry

Do-not-resuscitate orders in the OR—suspend or enforce?

AORN Journal, August, 2002 by Susan Goldberg

For years, it was common for perioperative personnel to suspend do-not-resuscitate (DNR) orders when a patient was wheeled through the OR doors because preoperative laboratory work, x-rays, and cardiograms usually had established the patient's ability to tolerate the procedure safely. During surgery, a patient's heart rate, blood pressure, and oxygen concentration are monitored constantly by state-of-the-art equipment that immediately detects any deviation from normal, and the means to resuscitate patients are available; however, retaining self-determination about medical care, especially the care patients receive if they are unable to speak for themselves, is a basic patient right. (1) Although health care professionals are dedicated to preserving life, advance directives (eg, living wills, powers of attorney, health care proxies) remain in effect until they are changed or nullified. (2) Caregivers must be able to cope with the ethical and moral consequences of withholding resuscitation efforts and respect a patient's wishes.

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Creating a hospital-wide policy that automatically suspends all DNR orders in the OR does not address a patient's right to self-determination. Instead of removing patients from the decisionmaking process, surgeons should include them in reconsidering the DNR order. Surgeons and patients can discuss the risks and how to approach them during surgery. Surgeons also should document the contents and results of this conversation. (3) When the patient's wishes are defined clearly, it is the surgeon's responsibility to alert the perioperative team to the patient's decision, clarify team members' understanding of the patient's directive, and, if necessary, replace any team member who might have an ethical conflict with the patient's instructions.

WHY ADVANCE DIRECTIVES?

At least 20% of adults in the United States have a written advance directive. (4) Patients being admitted to a hospital without an advance directive may be asked to sign a health care proxy. (5) People who go out of their way to obtain such documentation share a goal--they do not wish to have their life maintained by heroic measures, especially if there is no hope for recovery. In particular, patients with a terminal disease or a condition that would keep them dependent on others for total care may wish to sign a DNR order.

Do-not-resuscitate documents usually are created with the best of intentions and for a variety of reasons. Some people are horrified at the possibility of existing in a helpless state, and others might wish to spare family members the emotional and financial drain of a long illness. Although advance directives often are written by older adult or terminally ill patients, some are created by younger people who want their wishes respected in the event of an accident or unexpected illness. (6) These directives, however, can create an ethical conflict for some staff members. The basis for this conflict is the commitment among medical personnel to preserve life versus respect for patients' wishes. It is unethical for medical personnel to disregard patients' preferences and impose their own standards of behavior on patients, but many critical care nurses report that some physicians do disregard DNR requests. (7)

If medical personnel respect a patient's wish to withhold resuscitation efforts, could they be accused of participating in euthanasia or assisted suicide? Euthanasia is defined as "good death," but that is a simplified description. (8) The definition has been refined to include several gray areas, including passive euthanasia, which simply is allowing a patient to die. One case that illustrates passive euthanasia is the death of Nancy Cruzan, who was injured in an automobile accident that left her in a persistent vegetative state. She was kept alive only by nutrition administered through a feeding tube. When it was established beyond a doubt that there was no hope for her recovery, her parents requested that the tube feedings stop. Physicians refused, saying that removing the feeding tube was the same as starving Cruzan to death. Cruzan's parents fought the physicians all the way to the US Supreme Court and lost. At that point, they moved their daughter to another state where the feeding tube was removed and Cruzan died. (9)

Those who disagree with the Cruzans' decision argue that removing the feeding tube is a form of non-voluntary euthanasia (ie, involving a patient who cannot speak for himself or herself because of senility, brain damage, or a persistent vegetative state). They believe there is no moral difference between removing a feeding tube and actively causing a patient's death by administering a lethal injection. (10)

The administration of a lethal medication, either directly or by supplying a patient with a large amount of the medication, knowing that he or she probably will use it to overdose, is known as voluntary euthanasia or assisted suicide. These acts are illegal. One of the most famous advocates of assisted suicide is Jack Kevorkian, MD, who has been arrested and put on trial several times for his efforts to help dying patients. On Sept 17, 1998, he filmed himself administering a lethal injection to a patient and sent the videotape to the television show 60 Minutes. Shortly after the videotape aired, Dr Kevorkian was arrested and charged with premeditated murder. He was tried in April 1999 and convicted of second-degree murder. (11) He currently is serving a 10-year to 25-year prison sentence. (12)

Health Care Industry

Do-not-resuscitate orders in the OR—suspend or enforce?

AORN Journal, August, 2002 by Susan Goldberg

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