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Perioperative DNR Orders, Palliative Surgery, and Ethics
Perioperative Nursing Clinics 3 (2008) 223–232
Perioperative DNR Orders, Palliative Surgery, and Ethics Jackie L. Berlandi, RN, MS, CNOR, CNA-BC*, Janet Duncan, RN, MSN, CPNP Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
Everyday perioperative nurses care for patients hoping for a cure of an illness. Occasionally, however, patients who have an incurable illness require palliative surgery to relieve pain or improve quality of life. These patients may have do-not-resuscitate (DNR) orders that could present ethical challenges for members of the perioperative health care team. Do-not-resuscitate orders DNR guidelines were first developed in the 1970s in response to questions and requests by nurses who cared for patients at end of life [1]. These nurses realized that cardiopulmonary resuscitation (CPR) would often be administered even though the patient did not want it or staff knew it was unwarranted [1]. Many in the medical and nursing community believed and continue to believe that CPR is inappropriate in cases of physiologic futility [2]. The American Medical Association was the first professional organization to state that decisions not to resuscitate should be documented in progress notes and clearly communicated to all health care providers [3]. In 1992 the Joint Commission on Accreditation of Healthcare Organizations also required hospitals to develop protocols for patient involvement in care, including decisions about withholding of resuscitation measures and documentation of care decisions. The Omnibus Budget Reconciliation Act
* Corresponding author. E-mail address: [email protected]. edu (J.L. Berlandi).
of 1990, specifically the Patient Self-Determination Act, required institutions to have policies and information on patient rights to refuse treatment, and to develop advanced directives [4]. When patients are not competent to make decisions and no advanced directive exists, the family may speak for the patient using the substituted judgment standard [3]. DNR orders and implementation vary among institutions [5]. Without clear documentation and communication, DNR orders may be a source of misunderstanding among health care team members. A DNR order must be clearly defined so that patients, family members, and health care team members understand patient wishes if a life-threatening event occurs. A DNR order does not mean that patients are ‘‘giving up’’ or refusing treatment to make their life more comfortable or improve quality of life. A DNR order identifies the decision of a patient and care team regarding CPR during a life-ending event.
Organizational position statements DNR orders are often implemented when a cardiopulmonary arrest is expected to be a direct consequence of a patient’s underlying disease [1]. The belief is that the attempt to resuscitate would only prolong the time and possible suffering until death and not benefit the patient. A DNR order does not mean that treatment should be stopped nor that medical and nursing care should be eliminated [6]. DNR orders in the perioperative areas continue to be a conflicting and possibly confusing
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matter for health care workers. When DNR orders were first developed in the 1970s, many hospitals automatically suspended the DNR order before any surgical intervention, both elective and emergent [6]. This suspension frequently occurred without of the knowledge of the patient or patient surrogate. The automatic withdrawal was based on the belief that the role and impact of anesthesia could result in the need to resuscitate during the surgical procedure. Many anesthesiologists accept death as a result of disease but not as a direct result of an anesthesia complication [7]. Actions that are normally considered part of the administration of anesthesia may result in hemodynamic abnormalities, respiratory depression, or an iatrogenic event that requires resuscitative measures to sustain life. Some of these practice interventions, such as intubation, blood administration, invasive monitoring, and treatment of hemodynamic instability caused by anesthetic agents, could be classified as resuscitative measures. The intraoperative team may want the ability to intervene if necessary. Many health care providers are not aware of specific departmental policies addressing DNR orders during the perioperative phase of a patient’s hospitalization. They incorrectly believe that DNR orders are automatically suspended, with or without the patient’s knowledge or approval.
In the 1990s the American Society of Anesthesiologists (ASA), American College of Surgeons (ACS), and Association of periOperative Registered Nurses (AORN) all developed professional position statements addressing perioperative care of patients who have a DNR order. The ASA was the first to develop the guideline in 1993, entitled ‘‘Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders.’’ The guideline describes the need to review the DNR order with the patient or patient surrogate to clarify or modify directives based on the patient’s wishes [8,9]. The ASA guideline presents three scenarios an anesthesiologist can offer a patient who has a DNR order (Box 1). These must be communicated clearly so that the patient can understand the action and potential outcomes of each. The first is full attempt to resuscitate, for which the patient or designated surrogate requests full suspension of the DNR order and implementation of appropriate resuscitative procedures. If a DNR order is suspended during surgery, the duration of this suspension must be determined. Various factors must be considered when determining the duration of the suspension, including how long it takes for the anesthetics to resolve, length of procedure, and pulmonary function related to disease. A postoperative DNR order is reinstated by the primary physician involved in the patient’s
Box 1. Perioperative guidelines for do-not-resuscitate orders, Children’s Hospital, Boston Option 1: full resuscitation The patient desires that full resuscitative measure be used during surgery and in the postanesthesia care unit, regardless of the clinical situation. Option 2: limited resuscitation: procedure-specific The patient desires that full resuscitative measures be used, except certain specific procedures, such as chest compressions or electrical cardioversion. However, certain procedures are essential to providing anesthetic care (such as airway management and intravenous fluids). Refusal of these procedures would not be consistent with a request for anesthesia and surgery. Option 3: limited resuscitation: goal-specific The patient desires resuscitative efforts during surgery and in the postanesthesia care unit only if the adverse clinical events are believed to be temporary and reversible in the clinical judgment of the attending anesthesiologists and surgeons. This option requires the patient or surrogate to trust the judgment of the anesthesiologists and other caregivers to use resuscitative interventions judiciously based on their understanding of the patient’s values and goals of treatment. Courtesy of Children’s Hospital, Boston, MA; with permission.
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care with the agreement of the patient or patient’s surrogate, if necessary [1]. The second scenario is resuscitative measures determined by specific procedures to be performed. The patient or designated surrogate may elect to continue refusing specific resuscitation procedures, such as chest compressions. Anesthesiologists must clarify which procedures are necessary for the success of anesthesia and which are not essential. The third scenario is limited resuscitative measures in deference to the patient’s values or goals. The anesthesiologist and surgical team are permitted to use clinical judgment to support the goals and values of the patient or designated surrogate [8]. In 1994, the ACS developed the ‘‘Statement on Advance Directives by Patients: ‘Do Not Resuscitate’ in the Operating Room’’ [10]. This discussion of the DNR policy supports a review of the DNR order rather than instituting an automatic suspension of the DNR order. Furthermore, in 1995, AORN developed the position statement ‘‘Perioperative Care of Patients with Do-Not-Resuscitate (DNR) Orders,’’ which also supports reviewing the patient’s DNR order with the patient or patient’s surrogate, anesthesiologist, and surgeon [11]. The statement ‘‘Required reconsideration of DNR decisions ensures that risks and benefits of anesthesia and surgery are discussed by health care providers and patients or patients’ surrogate decision makers before surgery’’ outlines the necessary elements of a discussion with the patient and family [11]. All three professional organizations support required reconsideration of a patient’s DNR order before surgical intervention. When a patient or the patient’s family agrees to a DNR order, it is with the belief that the patient’s underlying disease will be the cause of cardiopulmonary arrest. Patients who have DNR orders and require surgery present other risks that must be discussed with the patient and family. Because perioperative nurses, surgeons, and anesthesiologists are infrequently involved or present when DNR measures are discussed with the family, issues related to surgical intervention and the administration of anesthesia may be unknown or not discussed at all. When surgery is considered, the appropriate physicians must discuss surgical intervention and anesthesia administration with the patient or patient’s surrogate. The remainder of the perioperative team, including nurses, surgical technologists,
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and residents who will be involved in the surgery, must be informed of the patient’s decision. A clear and informative discussion must occur with the whole surgical team so that all agree to support the perioperative plan regarding a DNR order. Palliative surgical procedures should be offered or provided to patients who have a DNR order with the understanding that that they will not have to undergo resuscitative measures or unwanted intensive care if complications occur [12]. If no discussion occurs with the patient or patient’s surrogate, the perioperative nurse must act as one of the patient’s advocates and question the need for required reconsideration of the DNR order. Therefore, the perioperative nurse must know the departmental policies on DNR orders. Ethical principles and do-not-resuscitate orders Automatically suspending DNR orders during the perioperative period and intervening with patient autonomy and self-determination are unethical [4]. Patients should not have to relinquish their autonomy and right to self-determination when undergoing surgery [13], and should not fear that other treatments may be withheld if they do not comply with a suspension. A DNR order does not tie the hands of a surgeon, anesthesiologist, or perioperative nurse if it is clear to all involved that a discussion has occurred with the patient or patient surrogate to determine the goals of the care. The perioperative nurse’s knowledge of hospital DNR policies is essential. As a patient advocate, the nurse must support the patient and implement a review of the DNR order. If a health care institution does not have a perioperative DNR policy, then the nurse may lead a multidisciplinary task force to develop one, incorporating ethical principles and leading the way for required reconsideration and review of DNR orders. Patients wish to be cared for with respect and to die with dignity. It is important that patients believe that their end-of-life wishes are followed and that they maintain control over some aspects of care toward the end of life. The principles that can support the perioperative care team while caring for patients who have DNR orders are autonomy, beneficence, nonmaleficence, and justice. The principles of veracity and fidelity also impact DNR orders in the operating room. The rule of double effect (RDE) may also help caregivers discuss care with patients who have DNR orders.
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Autonomy can mean self-governance, individual choice, freedom of will, and being one’s own person [14]. Patients who have a DNR order should be able to participate in any discussions about the order and surgical intervention. If the patient is incapable of making informed decisions, the patient’s surrogate has the autonomy to act on the patient’s behalf. The patient’s wishes should be heard and a priority in care. To promote autonomy, patients must be included in discussions with physicians and the multidisciplinary team to determine the need for a specific surgery, to review the DNR decision and the impact on the procedure, and to have sufficient information on the benefits and risks of anesthesia and surgery [15]. This discussion ideally occurs days before the preoperative waiting area and not moments before surgery. Patients may request that family members, friends, or other health care providers be present during this discussion to help make informed decisions. Any hospital policy that continues to automatically suspend all DNR orders intraoperatively and immediately in recovery areas does not support a patient’s right to autonomy and participation in decision making regarding health care [13,16]. Nonmaleficence is an obligation to not inflict harm intentionally. The saying ‘‘Above all (or first) do no harm’’ helps describe this concept [14]. A patient who has a DNR order may feel more harm would be done if the DNR order was suspended unknowingly and resuscitative measures were used that resulted in a worse condition. A terminally ill patient may feel that prolonging life with CPR is causing more harm than death [13]. When a patient has a DNR order, the decision has already been made that interventions may cause more harm than good. Beneficence is the moral obligation to act for the benefit of others or to do good. Beneficence is a positive act to prevent harm; the benefit of others is the driving factor [14]. An intraoperative care team caring for a patient who has a DNR order should be knowledgeable about the care the patient requested. The most common goal is to preserve life and provide care that will enhance health or improve health. Justice is to be fair and equitable. Justice is appropriate when considering what is due or owed [14]. A patient who has a DNR order who also requests surgery is justified in asking that the DNR order be followed according to the result of the required reconsideration discussion with the intraoperative team. Offering surgery and
treatments for those who will die may incur further ethical debate. What is justice if those who may be cured are not served because the terminally ill are [17]? The justice in caring for all patients is questioned. Veracity means truthfulness and honesty. These character traits of health professionals are highly regarded [14]. However, caregivers and family members may have great difficulty speaking openly and honestly about a DNR order or potential end of life. Definite answers regarding the outcomes or prognosis after palliative surgery may not exist. Fidelity is to act in good faith and keep promises, commitments, or oaths; it is to be true to one’s word [14]. When a patient who has a DNR order agrees to any intraoperative care, the team must do everything possible to implement the plan of care and respect patient wishes. For patients who want a modified DNR, this may be particularly challenging, because the intraoperative team members usually do not have a relationship with the patient before surgery. The rule of double effect (RDE) recognizes that an action may have good and bad outcomes. The RDE, also called the principle or doctrine of double effect, distinguishes between desired effects of an action or treatment and those that are unintended consequences [14]. The term double effect refers to the duality of the results [18], meaning that an action may have both the intended and unintended effects. The RDE looks at one’s intentions. The rule of double effect has four main components: (1) the act must be good or at least morally neutral; (2) bad effects are known but not intended; (3) the act cannot be a bad means to a good end; and (4) the benefit must be greater benefit than the risk [19]. Health care workers try to distinguish between intended results and foreseeable but unintended results [20]. According to the rule of double effect, the action is ethical if the harmful effect is not the intended one [14]. Staff may struggle with the patient’s decision to maintain a DNR order while undergoing surgery. They may need time to discuss the case and understand why patients request and are offered palliative surgery. The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements supports nurses in providing this care and helping to influence others gain knowledge in caring for these patients [21]. The AORN Ethics Task Force provided explications of the ANA’s Code of Ethics for Nurses
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with Interpretive Statements. These explications provide a framework for perioperative nurses to make ethical decisions and relate their practice to the ANA Code of Ethics [11]. If any member of the intraoperative care team has a conflict with the proposed treatment plan, this person should be allowed to request replacement with another caregiver. This request should be supported, unless no one is available to relieve the provider, because the patient cannot be abandoned. All measures should be taken to support the patient’s decision while also respecting the beliefs of the health care provider. Choosing surgery does not mean the patient wants to hasten death; in establishing a DNR, the patient acknowledges that if resuscitation is provided during surgery, the result could be a worse condition than before the surgery [19].
Procedure-directed do-not-resuscitate orders DNR orders in the operating room may be procedure-directed. The DNR includes a list of resuscitative procedures that can be checked ‘‘yes’’ or ‘‘no.’’ These orders clearly describe which procedures will be instituted during a cardiac arrest [3,13]. Procedure-directed DNR orders involve the need for patients and caregivers to identify all lifethreatening events that might occur during surgery and what to do. Caregivers believe little flexibility exists with a procedure list because restrictions exist on treatment for an unexpected outcome that could be easily remedied. Procedure-directed DNR orders offer clearer communication among many caregivers who may not be familiar with the patient. Most operating room personnel continue to use the proceduredirected DNR orders but often believe less flexibility exists and that these orders ‘‘tie their hands’’ [22].
Goal-directed do-not-resuscitate orders Goal-directed DNR orders focus on the patient’s goals, values, and preferences, and not specific procedures. Goal-directed DNR orders protect the patient’s autonomy and the normal working environment for caregivers in the operating room [22]. Goal-directed DNR orders allow the patient and family to discuss with caregivers the patient’s goals and values, particularly at end of life [13]. Patients explain to providers their desired outcomes, allowing the caregivers, especially the
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anesthesiologist and surgeon, to determine what measures can be taken to meet these goals. Goal-directed DNR orders are subjective and depend strongly on the communication and relationship between patient and physician [1]. Caregivers are granted more flexibility in deciding care and initiating interventions. With goal-directed DNR orders, a patient may decide to accept an intervention for a specific period, after which the intervention may be reevaluated in light of the patient’s goals (eg, patient agrees to postoperative intubation for 24 hours and then asks for reevaluation with withdrawal of mechanical support). With goal-directed DNR orders, the patient’s values, preferences, and goals are the focus. The goal-directed approach to DNR orders are more concerned with subjective and personal issues about quality of life before and after resuscitation [1]. With goal-directed DNR orders, some patients may decide to do everything to maintain life or promote comfort [22]. The goal-directed DNR orders provide health care workers more flexibility to use resuscitative measures they identify as appropriate to maintain or reach the patients outcome and goals during the surgical procedure or resuscitative encounter. One area of great concern is during the administration of anesthesia. Life-threatening episodes may occur as part of the anesthetic process, but these events are easily remedied with standard interventions, such as administering medication or brief cardiac compressions. These interventions would be initiated for any patient and not considered unusual, even for a patient who has a DNR. With goal-directed DNR orders, the surgeon and anesthesiologist may determine the care to administer based on their knowledge of the patient and the patient’s goals. A further challenge with goal-directed DNR orders is that the optimal situation is to have the physician involved with the original DNR order discussions be the same one present in the surgery. If this is not the case, the surgeon must clarify the DNR orders and communicate the plan to all involved in the surgery. Once in the operating room, consistency can be accomplished because the surgeon, anesthesiologist, and nursing staff remain throughout the intraoperative phase.
Death in the operating room Perioperative health care team members may believe that a patient should not die in the
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operating room. For some, the unspoken concern is that others will assume something went wrong and that may have been prevented. Occasionally, patients are in a full resuscitative mode during transport back to the intensive care unit so that the family can be present for the last moments. Allowing a patient to die in the operating room is difficult while following the principle of nonmaleficencedto do no wrong; staff must accept that death is not always causing or caused by harm. A goal-directed DNR death in the operating room may be the exact implementation of the DNR order. If a patient does not want life prolonged and wants primarily to be comfortable and pain-free, these goals are possible while under anesthesia. Having a patient die in the operating room is difficult because of how it has been reviewed. Will it be a legal manner? What went wrong, even when nothing went wrong? Is it important for the family to be with the patient during death? Will the state medical examiner have to be called or a mandatory quality assurance review conducted when a patient who has a DNR order dies in the operating room? How should physicians discuss with patients that if cardiac arrest caused by the irreversible underlying disease occurs during surgery, then resuscitative measures may be withheld because it may be classified as an expected death? In the past, the operating room was identified as a poor environment for end-of-life care. One concern is allowing family and clergy to be present at the time of death. Recognizing the continuum of care includes respect, autonomy, and individuality for patients, family, and caregivers. Staff must make end-of-life care possible in any setting. Is rushing a dying patient to another part of the hospital dignified or respectful? Steps can be taken to incorporate the same supportive caring practices of the dying patient in the operating room, intensive care unit, and hospital room. This process requires flexible thinking and management by the operating room staff and the opportunity to offer best practices when caring for patients at end of life. Families can be allowed to go into the operating room and be with their dying family member. Goal-directed DNR orders that may result in the patient dying can be supported in the operating room. If patients do not want any measures taken to prolong dying, then they should be allowed to die in the operating room with family members present.
Palliative surgery/care The Surgeons’ Palliative Care Workgroup in 2003 reported on the rich history of surgeons participating in and promoting palliative care [23]. Surgeons were involved early in the hospice movement and the well-known surgeon Balfour Mount is credited with creating the expression palliative care. In 1998, the Statement of Principles Guiding Care at the End of Life was developed by the American College of Surgeons Committee on Ethics, and by July of 2001 the American Board of Surgery required that certified surgeons have specialized training in palliative care. In their report, the palliative care workgroup formalized recommendations to introduce palliative care principles and techniques into surgical practice and education in the United States and Canada. The authors emphasize the need for expertise in embracing palliative care principles of symptom management, excellent communication skills, and understanding ethical issues, grief and bereavement, and spirituality as it relates to surgical procedures even near end of life. However, this report did not provide guidance for when a DNR order was established and how to consider this when an arrest occurs or a surgical procedure is decided. Several authors have suggested possible ways to consider this. Some would argue that patients who have DNR orders may be better served with a limited aggressive therapy order (LATO) [24]. These authors argue that CPR is more likely to be successful in three distinct circumstances: witnessed cardiopulmonary arrest with initial ventricular tachycardia or fibrillation, cardiac arrest in the operating room, and cardiac arrest resulting from readily identifiable iatrogenic complications. They assert that a patient who has a DNR order should choose whether to be resuscitated in these situations. Others entities, such as the ACS, ASA, and AORN, support the policy of required reconsideration for adults and children who have DNR orders before they undergo anesthesia or surgery [13]. Patients would choose from four options: suspend DNR, continue DNR, limit resuscitation interventions to procedures agreed on by the patient and provider, and limit resuscitation interventions to those that clinicians agree are consistent with patient-stated goals. These options must be discussed and documented thoroughly. How is it decided who should receive palliative surgical care? Little exists in the literature and
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scientific research or assessment to outline or define when this should occur [23]. The underlying principle and deciding factor should be to improve quality of life and provide pain or symptom relief. When determining surgical options for a patient who has a DNR order, the patient and family’s voice must be heard to determine the possible benefits of surgery. The patient’s wishes, with the understanding of the disease and prognosis, are the most important factor in deciding which surgical procedures, if any, should be performed [23]. Informed consent must include a realistic understanding of treatment goals and prognosis with or without treatment [23]. The prognosis may not change with surgical intervention, but quality of life may improve. Many caregivers may wonder why a patient who has a DNR order would undergo surgery and, further, has a right to request surgery? Some may view a DNR order as a decision to have no extraordinary measures to prolong life, and view surgery as an extraordinary measure. A DNR order may also be viewed as inconsistent with the goals of surgical intervention and perioperative care. Other providers may believe it is inappropriate for patients who have a DNR order to use ICU beds or operating room time because they do not want to live. However, patients who have DNR orders have decided that given their current health and circumstances, the burdens associated with CPR exceed the benefits [7]. Patients who have DNR orders who undergo surgery often do so to enhance their quality of life, decrease pain, or treat an unrelated health problem that has nothing to do with their underlying disease. Some surgical interventions that may improve the quality of life include the insertion of a gastrostomy tube for feeding purposes; a tunneled line for the use of antibiotics, hydration, or pain management; or a tracheotomy to enable a patient to leave the hospital with respiratory support. Other more invasive surgical interventions include debulking a painful tumor, or a bowel resection with a colostomy to relieve a bowel obstruction. Pediatric palliative care in the perioperative setting The American Academy of Pediatrics (AAP) in 2004 issued their clinical report on DNR orders for pediatric patients who require anesthesia and surgery. They also support ‘‘required reconsideration.’’ The DNR order is usually
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written to prevent resuscitation attempts when a child has experienced a life-ending event as a result of the underlying disease, without considering the implications of anesthesia and surgery. Most likely surgeons and anesthesiologists have not been part of the original DNR decision and must explain to parents and children, when appropriate, how this would apply during anesthesia and surgery. If a family chooses to suspend the DNR, the reinstatement time should be discussed. Goaldirected DNR orders may be less desirable for children, particularly if the surgeon or anesthesiologist does not have an established relationship with the child and parents. A DNR order based on procedure-specific resuscitation interventions may be preferable in this situation. Furthermore, staff participating in the anesthesia and operative procedure must be considered when any kind of DNR order exists (Fig. 1). This order must be discussed, and any team member who cannot honor the orders must be excused from the case and replaced. In response to the AAP report, Truog and colleagues [12] note that the guidelines are welcomed, but practice is slow to change. As pediatrics embraces family-centered care, partnership in decision making, and the value of quality of life alongside the availability of highly technical medical and surgical interventions, caregivers must also strive to inform, recommend, and honor patient and family values and goals. Palliative care for children younger than 18 years is similar to that for adults. It is care that ‘‘seeks to prevent or relieve the physical and emotional distress produced by a life-threatening medical condition or its treatment, to help patients with such conditions and their families live as normally as possible, and to provide them with timely and accurate information and support in decision-making’’ [25]. For parents or guardians of children with life-threatening conditions, resuscitation may be discussed with medical staff, particularly as medical interventions become limited or the burden of medical treatment is deemed to outweigh the benefit. Family members and medical staff may have many misconceptions that a resuscitation order is not necessary until the child is viewed as ‘‘dying.’’ Regardless of the timing, DNR and do-notintubate orders have become increasingly complex. Although palliative care teams often teach primary providers the importance of recommending these orders to families, providers
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Fig. 1. Clinical decision making and palliative surgery. (From Ferrell BR, Chu DZJ, Wagman L, et al. Online exclusive: patient and surgeon decision making regarding surgery for advanced cancer. Oncol Nurs Forum 2003;30(6):E108; with permission).
often ask ‘‘what do you want us to do?’’ Parents are then faced with the terrible burden of having to choose care interventions, rather than agreeing to recommendations, discussing benefits and burdens, and carefully considering what options are most consistent with the goals of the child or family. When a surgical option is recommended to enhance the child’s comfort or quality of life, this issue becomes even further complicated for parents. Is surgery for symptom management or avoidance of symptoms anticipated? One definition of palliative surgery offered is ‘‘any invasive procedure in which the main intention is to mitigate physical symptoms in patients with incurable disease without causing premature death’’ [26]. The authors, however, qualify this definition further, warning that it may be impossible to know if a certain surgical procedure will hasten death. This definition refers to physical symptoms, not quality of life, because surgery is a physical action; it does not consider when curative surgery becomes palliative or when surgery is used for
prophylactic treatment. The authors have attempted a definition that is morally acceptable in all regards, while raising qualifications that may be morally acceptable but require further deliberation and attention. In a recent qualitative study, Ferrell and colleagues [27] found that surgeons report that symptoms were the motivation to consider surgery with the goal of symptom relief. However, although patients considered physical symptom relief primary, they were also influenced by the social impact of improving symptoms and the need to maintain hope. These researchers developed a helpful algorithm to assist clinical decision making when considering palliative surgery (see Fig. 1). Ethics in palliative care Sometimes families ask to ‘‘do everything possible,’’ but this may not be beneficial or helpful to the patient. When requests are made from families to do everything possible,
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physicians must tell them what this truly means and why, although medical technology abounds, it may not be possible or warranted for a particular patient [26]. Patient autonomy is a major focus of health care today, and many experts may believe that satisfying the wishes of patients and their relatives is important. However, palliative surgery should not be offered to meet emotional, existential, and psychological needs so that patients and their relatives do not feel caregivers have ‘‘given up’’ or lost hope [26]. Families may request that everything possible be done so that they have no regrets later, but futile or harmful treatment should not be offered to patients and their families. A patient’s rights and autonomy should be respected, and honest information is important [26]. Benevolence also includes compassion when caring for a patient who has a DNR order. Compassion and benevolence are necessary for caring for all patients, but health care workers must be aware that not all benevolent actions end in doing good [26]. To maintain the dignity of the patient and autonomy of the patient, patients and families must be involved in all discussions related to care and active in the decision making. When a decision is made to move from lifesustaining therapies to palliative care, patients should be involved in discussions and the decision-making processes. If able to participate in decision making, the patient’s wishes should take precedence over any wish that was expressed in a previously written advanced directive or decisions [28]. The decision making should be a shared process that considers the pros and cons of any palliative intervention and involves careful deliberation [29]. Time should not be considered when trying to determine the wishes of a patient who has a DNR order; it is important to do the right thing.
planned and hopeful outcome but also what resuscitative measures will be taken that meet the goals of the patient. These steps may include transferring the patient to another hospital, finding alternative team members, or requesting assistance from the hospital ethics committee [6].
Legal considerations
References
Physicians and hospitals have been sued because patients were resuscitated against their or the family’s wish [30]. To avoid this situation, clear communication should occur, with concise documentation of discussions between patients, family, and health care providers. Physicians must specifically document and communicate to all health care team members to ensure that patient wishes are understood and respected [30]. For operating room personnel, this discussion must include not only the surgical procedure
Summary The best quality of life described by patients and families is best accomplished with shared decision making among all involved [29]. No simple guidelines exist on how to care for patients who have DNR orders. Patient decisions should be made in a noncoercive environment and should be respected without any consequences to care [31]. Dignity must also be maintained and health care workers should try and stay impartial, even if staff know patients well [31]. Health care providers must accept the wishes and decisions of patients, and incorporate these into care. Discussions and clear documentation are important to complete before surgery. Patients can accept more responsibility for care given when all information is provided, questions are answered and time is offered to make an informed decision on DNR orders in the operating room [32]. This process must occur so that care providers and staff in the operating room are knowledgeable and agree to the care plan. Currently, DNR orders in the operating room that are procedure-driven outline what will not be done for the patient. Focusing on what will be done for the patient in the end stages of life who is hoping for a ‘‘good death’’ may be best [3]. Hospitals must develop policies and implement practices that support and respect the needs of patients who have a DNR order, and also those of the operating room staff.
[1] Fallat ME, Deshpande JK. Do-not-resuscitate orders for pediatric patients who require anesthesia and surgery. Pediatrics 2004;114(6):1686–92. [2] Bacchetta MD, Eachempati SR, Fins JJ, et al. Factors influencing DNR decision-making in a surgical ICU. J Am Coll Surg 2006;202(6):995–1000. [3] Burns JP, Edwards J, Johnson J, et al. Do-notresuscitate order after 25 years. Crit Care Med 2003;31(5):1543–50. [4] Coopmans VC, Gries CA. CRNA awareness and experience with perioperative DNR orders. AANA J 2000;68(3):247–56.
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[5] Cantor MD, Braddock CH III, Derse AR, et al. Do-not-resuscitate orders and medical futility. Arch Intern Med 2003;163(22):2689–94. [6] Reeder JM. Do-not-resuscitate orders in the operating room. AORN J 1993;57(4):947–51. [7] Truog RD, Waisel DB. Do-not-resuscitate orders: from the ward to the operating room; from procedures to goals. Int Anesthesiol Clin 2001;39(3): 53–65. [8] American Society of AnesthesiologistsASA. Ethical guidelines for the anesthesia care of patients with do-not-resuscitate orders. Available at: http:// www.asahq.org/publicationsAndServices/standards/ 09.html. Accessed December 3, 2007. [9] American Society of PeriAnesthesia Nurses (ASPAN). A position statement on the perianesthesia patient with a do-not-resuscitate advance directive. Available at: http://www.aspan.org/PosStmts7.htm. Accessed December 3, 2007. [10] American College of Surgeons. Statement on advance directives by patients. ‘‘Do Not Resuscitate’’ in the operating room, in, 1994. Available at: http://www.facs.org/fellows_infostatements/st-19. html. Accessed December, 2007. [11] AORN: standards, recommended practices, and guidelines. Denver: AORN; 2007. [12] Truog RD, Waisel DB, Burns JP. Do-not-resuscitate orders in the surgical setting. Lancet 2005;365(9461): 733–5. [13] Guarisco KK. Managing do-not-resuscitate orders in the perianesthesia period. J Perianesth Nurs 2004;19(5):300–7. [14] Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th edition. New York: Oxford University Press; 2001. [15] Goldberg S. Do-not-resuscitate orders in the ORd suspend or enforce? AORN J 2002;76(2):296–9. [16] Ardagh M. Futility has no utility in resuscitation medicine. J Med Ethics 2000;26(5):396–9. [17] Chrystal-Frances E. Palliative care: a discussion of management and ethical issues. Nurs Forum 2003; 38(2):25–8. [18] Boyle J. Medical ethics and double effect: the case of terminal sedation. Theor Med Bioeth 2004;25(1):51–60. [19] Demme RA, Singer EA, Greenlaw J, et al. Ethical issues in palliative care. Anesthesiol Clin 2006; 24(1):129–44.
[20] Baumrucker SJ, Craig G, Stolick M, et al. Case study: sedation for palliation of terminal symptoms (SPTS), and nutrition and hydration at end of life. Am J Hosp Palliat Care 2005;22(2):153–7. [21] American Nurses Association. Code of ethics for nurses with interpretive statements. Washington, D.C.: American Nurses Association; 2001. [22] Truog RD, Waisel DB, Burns JP. DNR in the OR: a goal-directed approach. Anesthesiology 1999; 90(1):289–95. [23] Dunn GK, Milch RA. Office of promoting excellence in end-of-life care: surgeon’s palliative care workgroup report from the field. J Am Coll Surg 2003;197(4):661–86. [24] Choudhry NK, Choudhry S, Singer PA. CPR for patients labeled DNR: the role of the limited aggressive therapy order. Ann Intern Med 2003;138(1): 65–8. [25] Field MJ, Behrman RE, Institute of Medicine (U.S.), et al. When children die: improving palliative and end-of-life care for children and their families. Washington, D.C.: National Academies Press; 2003. [26] Hofmann B, Haheim LL, Soreide JA. Ethics of palliative surgery in patients with cancer. Br J Surg 2005;92(7):802–9. [27] Ferrell BR, Chu DZJ, Wagman L, et al. Online exclusive: patient and surgeon decision making regarding surgery for advanced cancer. Oncol Nurs Forum 2003;30(6):E106–14. [28] Pawlik TM, Curley SA. Ethical issues in surgical palliative care: am I killing the patient by ‘‘letting him go’’? Surg Clin North Am 2005;85(2): 273–86. [29] Hermsen M, ten Have H. Decision-making in palliative care practice and the need for moral deliberation: a qualitative study. Patient Educ Couns 2005;56(3):268–75. [30] Waisel DB, Burns JP, Johnson JA, et al. Guidelines for perioperative do-not-resuscitate policies. J Clin Anesth 2002;14(6):467–73. [31] Arraf K, Cox G, Oberle K. Using the Canadian code of ethics for registered nurses to explore ethics in palliative care research. Nurs Ethics 2004;11(6): 600–9. [32] Roberts M. Do-not-resuscitate orders in the ORd do they work for the patient. AORN J 2002;76(2): 242–4.
Perioperative DNR Orders, Palliative Surgery, and Ethics Jackie L. Berlandi, RN, MS, CNOR, CNA-BC*, Janet Duncan, RN, MSN, CPNP Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
Everyday perioperative nurses care for patients hoping for a cure of an illness. Occasionally, however, patients who have an incurable illness require palliative surgery to relieve pain or improve quality of life. These patients may have do-not-resuscitate (DNR) orders that could present ethical challenges for members of the perioperative health care team. Do-not-resuscitate orders DNR guidelines were first developed in the 1970s in response to questions and requests by nurses who cared for patients at end of life [1]. These nurses realized that cardiopulmonary resuscitation (CPR) would often be administered even though the patient did not want it or staff knew it was unwarranted [1]. Many in the medical and nursing community believed and continue to believe that CPR is inappropriate in cases of physiologic futility [2]. The American Medical Association was the first professional organization to state that decisions not to resuscitate should be documented in progress notes and clearly communicated to all health care providers [3]. In 1992 the Joint Commission on Accreditation of Healthcare Organizations also required hospitals to develop protocols for patient involvement in care, including decisions about withholding of resuscitation measures and documentation of care decisions. The Omnibus Budget Reconciliation Act
* Corresponding author. E-mail address: [email protected]. edu (J.L. Berlandi).
of 1990, specifically the Patient Self-Determination Act, required institutions to have policies and information on patient rights to refuse treatment, and to develop advanced directives [4]. When patients are not competent to make decisions and no advanced directive exists, the family may speak for the patient using the substituted judgment standard [3]. DNR orders and implementation vary among institutions [5]. Without clear documentation and communication, DNR orders may be a source of misunderstanding among health care team members. A DNR order must be clearly defined so that patients, family members, and health care team members understand patient wishes if a life-threatening event occurs. A DNR order does not mean that patients are ‘‘giving up’’ or refusing treatment to make their life more comfortable or improve quality of life. A DNR order identifies the decision of a patient and care team regarding CPR during a life-ending event.
Organizational position statements DNR orders are often implemented when a cardiopulmonary arrest is expected to be a direct consequence of a patient’s underlying disease [1]. The belief is that the attempt to resuscitate would only prolong the time and possible suffering until death and not benefit the patient. A DNR order does not mean that treatment should be stopped nor that medical and nursing care should be eliminated [6]. DNR orders in the perioperative areas continue to be a conflicting and possibly confusing
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matter for health care workers. When DNR orders were first developed in the 1970s, many hospitals automatically suspended the DNR order before any surgical intervention, both elective and emergent [6]. This suspension frequently occurred without of the knowledge of the patient or patient surrogate. The automatic withdrawal was based on the belief that the role and impact of anesthesia could result in the need to resuscitate during the surgical procedure. Many anesthesiologists accept death as a result of disease but not as a direct result of an anesthesia complication [7]. Actions that are normally considered part of the administration of anesthesia may result in hemodynamic abnormalities, respiratory depression, or an iatrogenic event that requires resuscitative measures to sustain life. Some of these practice interventions, such as intubation, blood administration, invasive monitoring, and treatment of hemodynamic instability caused by anesthetic agents, could be classified as resuscitative measures. The intraoperative team may want the ability to intervene if necessary. Many health care providers are not aware of specific departmental policies addressing DNR orders during the perioperative phase of a patient’s hospitalization. They incorrectly believe that DNR orders are automatically suspended, with or without the patient’s knowledge or approval.
In the 1990s the American Society of Anesthesiologists (ASA), American College of Surgeons (ACS), and Association of periOperative Registered Nurses (AORN) all developed professional position statements addressing perioperative care of patients who have a DNR order. The ASA was the first to develop the guideline in 1993, entitled ‘‘Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders.’’ The guideline describes the need to review the DNR order with the patient or patient surrogate to clarify or modify directives based on the patient’s wishes [8,9]. The ASA guideline presents three scenarios an anesthesiologist can offer a patient who has a DNR order (Box 1). These must be communicated clearly so that the patient can understand the action and potential outcomes of each. The first is full attempt to resuscitate, for which the patient or designated surrogate requests full suspension of the DNR order and implementation of appropriate resuscitative procedures. If a DNR order is suspended during surgery, the duration of this suspension must be determined. Various factors must be considered when determining the duration of the suspension, including how long it takes for the anesthetics to resolve, length of procedure, and pulmonary function related to disease. A postoperative DNR order is reinstated by the primary physician involved in the patient’s
Box 1. Perioperative guidelines for do-not-resuscitate orders, Children’s Hospital, Boston Option 1: full resuscitation The patient desires that full resuscitative measure be used during surgery and in the postanesthesia care unit, regardless of the clinical situation. Option 2: limited resuscitation: procedure-specific The patient desires that full resuscitative measures be used, except certain specific procedures, such as chest compressions or electrical cardioversion. However, certain procedures are essential to providing anesthetic care (such as airway management and intravenous fluids). Refusal of these procedures would not be consistent with a request for anesthesia and surgery. Option 3: limited resuscitation: goal-specific The patient desires resuscitative efforts during surgery and in the postanesthesia care unit only if the adverse clinical events are believed to be temporary and reversible in the clinical judgment of the attending anesthesiologists and surgeons. This option requires the patient or surrogate to trust the judgment of the anesthesiologists and other caregivers to use resuscitative interventions judiciously based on their understanding of the patient’s values and goals of treatment. Courtesy of Children’s Hospital, Boston, MA; with permission.
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care with the agreement of the patient or patient’s surrogate, if necessary [1]. The second scenario is resuscitative measures determined by specific procedures to be performed. The patient or designated surrogate may elect to continue refusing specific resuscitation procedures, such as chest compressions. Anesthesiologists must clarify which procedures are necessary for the success of anesthesia and which are not essential. The third scenario is limited resuscitative measures in deference to the patient’s values or goals. The anesthesiologist and surgical team are permitted to use clinical judgment to support the goals and values of the patient or designated surrogate [8]. In 1994, the ACS developed the ‘‘Statement on Advance Directives by Patients: ‘Do Not Resuscitate’ in the Operating Room’’ [10]. This discussion of the DNR policy supports a review of the DNR order rather than instituting an automatic suspension of the DNR order. Furthermore, in 1995, AORN developed the position statement ‘‘Perioperative Care of Patients with Do-Not-Resuscitate (DNR) Orders,’’ which also supports reviewing the patient’s DNR order with the patient or patient’s surrogate, anesthesiologist, and surgeon [11]. The statement ‘‘Required reconsideration of DNR decisions ensures that risks and benefits of anesthesia and surgery are discussed by health care providers and patients or patients’ surrogate decision makers before surgery’’ outlines the necessary elements of a discussion with the patient and family [11]. All three professional organizations support required reconsideration of a patient’s DNR order before surgical intervention. When a patient or the patient’s family agrees to a DNR order, it is with the belief that the patient’s underlying disease will be the cause of cardiopulmonary arrest. Patients who have DNR orders and require surgery present other risks that must be discussed with the patient and family. Because perioperative nurses, surgeons, and anesthesiologists are infrequently involved or present when DNR measures are discussed with the family, issues related to surgical intervention and the administration of anesthesia may be unknown or not discussed at all. When surgery is considered, the appropriate physicians must discuss surgical intervention and anesthesia administration with the patient or patient’s surrogate. The remainder of the perioperative team, including nurses, surgical technologists,
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and residents who will be involved in the surgery, must be informed of the patient’s decision. A clear and informative discussion must occur with the whole surgical team so that all agree to support the perioperative plan regarding a DNR order. Palliative surgical procedures should be offered or provided to patients who have a DNR order with the understanding that that they will not have to undergo resuscitative measures or unwanted intensive care if complications occur [12]. If no discussion occurs with the patient or patient’s surrogate, the perioperative nurse must act as one of the patient’s advocates and question the need for required reconsideration of the DNR order. Therefore, the perioperative nurse must know the departmental policies on DNR orders. Ethical principles and do-not-resuscitate orders Automatically suspending DNR orders during the perioperative period and intervening with patient autonomy and self-determination are unethical [4]. Patients should not have to relinquish their autonomy and right to self-determination when undergoing surgery [13], and should not fear that other treatments may be withheld if they do not comply with a suspension. A DNR order does not tie the hands of a surgeon, anesthesiologist, or perioperative nurse if it is clear to all involved that a discussion has occurred with the patient or patient surrogate to determine the goals of the care. The perioperative nurse’s knowledge of hospital DNR policies is essential. As a patient advocate, the nurse must support the patient and implement a review of the DNR order. If a health care institution does not have a perioperative DNR policy, then the nurse may lead a multidisciplinary task force to develop one, incorporating ethical principles and leading the way for required reconsideration and review of DNR orders. Patients wish to be cared for with respect and to die with dignity. It is important that patients believe that their end-of-life wishes are followed and that they maintain control over some aspects of care toward the end of life. The principles that can support the perioperative care team while caring for patients who have DNR orders are autonomy, beneficence, nonmaleficence, and justice. The principles of veracity and fidelity also impact DNR orders in the operating room. The rule of double effect (RDE) may also help caregivers discuss care with patients who have DNR orders.
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Autonomy can mean self-governance, individual choice, freedom of will, and being one’s own person [14]. Patients who have a DNR order should be able to participate in any discussions about the order and surgical intervention. If the patient is incapable of making informed decisions, the patient’s surrogate has the autonomy to act on the patient’s behalf. The patient’s wishes should be heard and a priority in care. To promote autonomy, patients must be included in discussions with physicians and the multidisciplinary team to determine the need for a specific surgery, to review the DNR decision and the impact on the procedure, and to have sufficient information on the benefits and risks of anesthesia and surgery [15]. This discussion ideally occurs days before the preoperative waiting area and not moments before surgery. Patients may request that family members, friends, or other health care providers be present during this discussion to help make informed decisions. Any hospital policy that continues to automatically suspend all DNR orders intraoperatively and immediately in recovery areas does not support a patient’s right to autonomy and participation in decision making regarding health care [13,16]. Nonmaleficence is an obligation to not inflict harm intentionally. The saying ‘‘Above all (or first) do no harm’’ helps describe this concept [14]. A patient who has a DNR order may feel more harm would be done if the DNR order was suspended unknowingly and resuscitative measures were used that resulted in a worse condition. A terminally ill patient may feel that prolonging life with CPR is causing more harm than death [13]. When a patient has a DNR order, the decision has already been made that interventions may cause more harm than good. Beneficence is the moral obligation to act for the benefit of others or to do good. Beneficence is a positive act to prevent harm; the benefit of others is the driving factor [14]. An intraoperative care team caring for a patient who has a DNR order should be knowledgeable about the care the patient requested. The most common goal is to preserve life and provide care that will enhance health or improve health. Justice is to be fair and equitable. Justice is appropriate when considering what is due or owed [14]. A patient who has a DNR order who also requests surgery is justified in asking that the DNR order be followed according to the result of the required reconsideration discussion with the intraoperative team. Offering surgery and
treatments for those who will die may incur further ethical debate. What is justice if those who may be cured are not served because the terminally ill are [17]? The justice in caring for all patients is questioned. Veracity means truthfulness and honesty. These character traits of health professionals are highly regarded [14]. However, caregivers and family members may have great difficulty speaking openly and honestly about a DNR order or potential end of life. Definite answers regarding the outcomes or prognosis after palliative surgery may not exist. Fidelity is to act in good faith and keep promises, commitments, or oaths; it is to be true to one’s word [14]. When a patient who has a DNR order agrees to any intraoperative care, the team must do everything possible to implement the plan of care and respect patient wishes. For patients who want a modified DNR, this may be particularly challenging, because the intraoperative team members usually do not have a relationship with the patient before surgery. The rule of double effect (RDE) recognizes that an action may have good and bad outcomes. The RDE, also called the principle or doctrine of double effect, distinguishes between desired effects of an action or treatment and those that are unintended consequences [14]. The term double effect refers to the duality of the results [18], meaning that an action may have both the intended and unintended effects. The RDE looks at one’s intentions. The rule of double effect has four main components: (1) the act must be good or at least morally neutral; (2) bad effects are known but not intended; (3) the act cannot be a bad means to a good end; and (4) the benefit must be greater benefit than the risk [19]. Health care workers try to distinguish between intended results and foreseeable but unintended results [20]. According to the rule of double effect, the action is ethical if the harmful effect is not the intended one [14]. Staff may struggle with the patient’s decision to maintain a DNR order while undergoing surgery. They may need time to discuss the case and understand why patients request and are offered palliative surgery. The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements supports nurses in providing this care and helping to influence others gain knowledge in caring for these patients [21]. The AORN Ethics Task Force provided explications of the ANA’s Code of Ethics for Nurses
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with Interpretive Statements. These explications provide a framework for perioperative nurses to make ethical decisions and relate their practice to the ANA Code of Ethics [11]. If any member of the intraoperative care team has a conflict with the proposed treatment plan, this person should be allowed to request replacement with another caregiver. This request should be supported, unless no one is available to relieve the provider, because the patient cannot be abandoned. All measures should be taken to support the patient’s decision while also respecting the beliefs of the health care provider. Choosing surgery does not mean the patient wants to hasten death; in establishing a DNR, the patient acknowledges that if resuscitation is provided during surgery, the result could be a worse condition than before the surgery [19].
Procedure-directed do-not-resuscitate orders DNR orders in the operating room may be procedure-directed. The DNR includes a list of resuscitative procedures that can be checked ‘‘yes’’ or ‘‘no.’’ These orders clearly describe which procedures will be instituted during a cardiac arrest [3,13]. Procedure-directed DNR orders involve the need for patients and caregivers to identify all lifethreatening events that might occur during surgery and what to do. Caregivers believe little flexibility exists with a procedure list because restrictions exist on treatment for an unexpected outcome that could be easily remedied. Procedure-directed DNR orders offer clearer communication among many caregivers who may not be familiar with the patient. Most operating room personnel continue to use the proceduredirected DNR orders but often believe less flexibility exists and that these orders ‘‘tie their hands’’ [22].
Goal-directed do-not-resuscitate orders Goal-directed DNR orders focus on the patient’s goals, values, and preferences, and not specific procedures. Goal-directed DNR orders protect the patient’s autonomy and the normal working environment for caregivers in the operating room [22]. Goal-directed DNR orders allow the patient and family to discuss with caregivers the patient’s goals and values, particularly at end of life [13]. Patients explain to providers their desired outcomes, allowing the caregivers, especially the
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anesthesiologist and surgeon, to determine what measures can be taken to meet these goals. Goal-directed DNR orders are subjective and depend strongly on the communication and relationship between patient and physician [1]. Caregivers are granted more flexibility in deciding care and initiating interventions. With goal-directed DNR orders, a patient may decide to accept an intervention for a specific period, after which the intervention may be reevaluated in light of the patient’s goals (eg, patient agrees to postoperative intubation for 24 hours and then asks for reevaluation with withdrawal of mechanical support). With goal-directed DNR orders, the patient’s values, preferences, and goals are the focus. The goal-directed approach to DNR orders are more concerned with subjective and personal issues about quality of life before and after resuscitation [1]. With goal-directed DNR orders, some patients may decide to do everything to maintain life or promote comfort [22]. The goal-directed DNR orders provide health care workers more flexibility to use resuscitative measures they identify as appropriate to maintain or reach the patients outcome and goals during the surgical procedure or resuscitative encounter. One area of great concern is during the administration of anesthesia. Life-threatening episodes may occur as part of the anesthetic process, but these events are easily remedied with standard interventions, such as administering medication or brief cardiac compressions. These interventions would be initiated for any patient and not considered unusual, even for a patient who has a DNR. With goal-directed DNR orders, the surgeon and anesthesiologist may determine the care to administer based on their knowledge of the patient and the patient’s goals. A further challenge with goal-directed DNR orders is that the optimal situation is to have the physician involved with the original DNR order discussions be the same one present in the surgery. If this is not the case, the surgeon must clarify the DNR orders and communicate the plan to all involved in the surgery. Once in the operating room, consistency can be accomplished because the surgeon, anesthesiologist, and nursing staff remain throughout the intraoperative phase.
Death in the operating room Perioperative health care team members may believe that a patient should not die in the
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operating room. For some, the unspoken concern is that others will assume something went wrong and that may have been prevented. Occasionally, patients are in a full resuscitative mode during transport back to the intensive care unit so that the family can be present for the last moments. Allowing a patient to die in the operating room is difficult while following the principle of nonmaleficencedto do no wrong; staff must accept that death is not always causing or caused by harm. A goal-directed DNR death in the operating room may be the exact implementation of the DNR order. If a patient does not want life prolonged and wants primarily to be comfortable and pain-free, these goals are possible while under anesthesia. Having a patient die in the operating room is difficult because of how it has been reviewed. Will it be a legal manner? What went wrong, even when nothing went wrong? Is it important for the family to be with the patient during death? Will the state medical examiner have to be called or a mandatory quality assurance review conducted when a patient who has a DNR order dies in the operating room? How should physicians discuss with patients that if cardiac arrest caused by the irreversible underlying disease occurs during surgery, then resuscitative measures may be withheld because it may be classified as an expected death? In the past, the operating room was identified as a poor environment for end-of-life care. One concern is allowing family and clergy to be present at the time of death. Recognizing the continuum of care includes respect, autonomy, and individuality for patients, family, and caregivers. Staff must make end-of-life care possible in any setting. Is rushing a dying patient to another part of the hospital dignified or respectful? Steps can be taken to incorporate the same supportive caring practices of the dying patient in the operating room, intensive care unit, and hospital room. This process requires flexible thinking and management by the operating room staff and the opportunity to offer best practices when caring for patients at end of life. Families can be allowed to go into the operating room and be with their dying family member. Goal-directed DNR orders that may result in the patient dying can be supported in the operating room. If patients do not want any measures taken to prolong dying, then they should be allowed to die in the operating room with family members present.
Palliative surgery/care The Surgeons’ Palliative Care Workgroup in 2003 reported on the rich history of surgeons participating in and promoting palliative care [23]. Surgeons were involved early in the hospice movement and the well-known surgeon Balfour Mount is credited with creating the expression palliative care. In 1998, the Statement of Principles Guiding Care at the End of Life was developed by the American College of Surgeons Committee on Ethics, and by July of 2001 the American Board of Surgery required that certified surgeons have specialized training in palliative care. In their report, the palliative care workgroup formalized recommendations to introduce palliative care principles and techniques into surgical practice and education in the United States and Canada. The authors emphasize the need for expertise in embracing palliative care principles of symptom management, excellent communication skills, and understanding ethical issues, grief and bereavement, and spirituality as it relates to surgical procedures even near end of life. However, this report did not provide guidance for when a DNR order was established and how to consider this when an arrest occurs or a surgical procedure is decided. Several authors have suggested possible ways to consider this. Some would argue that patients who have DNR orders may be better served with a limited aggressive therapy order (LATO) [24]. These authors argue that CPR is more likely to be successful in three distinct circumstances: witnessed cardiopulmonary arrest with initial ventricular tachycardia or fibrillation, cardiac arrest in the operating room, and cardiac arrest resulting from readily identifiable iatrogenic complications. They assert that a patient who has a DNR order should choose whether to be resuscitated in these situations. Others entities, such as the ACS, ASA, and AORN, support the policy of required reconsideration for adults and children who have DNR orders before they undergo anesthesia or surgery [13]. Patients would choose from four options: suspend DNR, continue DNR, limit resuscitation interventions to procedures agreed on by the patient and provider, and limit resuscitation interventions to those that clinicians agree are consistent with patient-stated goals. These options must be discussed and documented thoroughly. How is it decided who should receive palliative surgical care? Little exists in the literature and
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scientific research or assessment to outline or define when this should occur [23]. The underlying principle and deciding factor should be to improve quality of life and provide pain or symptom relief. When determining surgical options for a patient who has a DNR order, the patient and family’s voice must be heard to determine the possible benefits of surgery. The patient’s wishes, with the understanding of the disease and prognosis, are the most important factor in deciding which surgical procedures, if any, should be performed [23]. Informed consent must include a realistic understanding of treatment goals and prognosis with or without treatment [23]. The prognosis may not change with surgical intervention, but quality of life may improve. Many caregivers may wonder why a patient who has a DNR order would undergo surgery and, further, has a right to request surgery? Some may view a DNR order as a decision to have no extraordinary measures to prolong life, and view surgery as an extraordinary measure. A DNR order may also be viewed as inconsistent with the goals of surgical intervention and perioperative care. Other providers may believe it is inappropriate for patients who have a DNR order to use ICU beds or operating room time because they do not want to live. However, patients who have DNR orders have decided that given their current health and circumstances, the burdens associated with CPR exceed the benefits [7]. Patients who have DNR orders who undergo surgery often do so to enhance their quality of life, decrease pain, or treat an unrelated health problem that has nothing to do with their underlying disease. Some surgical interventions that may improve the quality of life include the insertion of a gastrostomy tube for feeding purposes; a tunneled line for the use of antibiotics, hydration, or pain management; or a tracheotomy to enable a patient to leave the hospital with respiratory support. Other more invasive surgical interventions include debulking a painful tumor, or a bowel resection with a colostomy to relieve a bowel obstruction. Pediatric palliative care in the perioperative setting The American Academy of Pediatrics (AAP) in 2004 issued their clinical report on DNR orders for pediatric patients who require anesthesia and surgery. They also support ‘‘required reconsideration.’’ The DNR order is usually
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written to prevent resuscitation attempts when a child has experienced a life-ending event as a result of the underlying disease, without considering the implications of anesthesia and surgery. Most likely surgeons and anesthesiologists have not been part of the original DNR decision and must explain to parents and children, when appropriate, how this would apply during anesthesia and surgery. If a family chooses to suspend the DNR, the reinstatement time should be discussed. Goaldirected DNR orders may be less desirable for children, particularly if the surgeon or anesthesiologist does not have an established relationship with the child and parents. A DNR order based on procedure-specific resuscitation interventions may be preferable in this situation. Furthermore, staff participating in the anesthesia and operative procedure must be considered when any kind of DNR order exists (Fig. 1). This order must be discussed, and any team member who cannot honor the orders must be excused from the case and replaced. In response to the AAP report, Truog and colleagues [12] note that the guidelines are welcomed, but practice is slow to change. As pediatrics embraces family-centered care, partnership in decision making, and the value of quality of life alongside the availability of highly technical medical and surgical interventions, caregivers must also strive to inform, recommend, and honor patient and family values and goals. Palliative care for children younger than 18 years is similar to that for adults. It is care that ‘‘seeks to prevent or relieve the physical and emotional distress produced by a life-threatening medical condition or its treatment, to help patients with such conditions and their families live as normally as possible, and to provide them with timely and accurate information and support in decision-making’’ [25]. For parents or guardians of children with life-threatening conditions, resuscitation may be discussed with medical staff, particularly as medical interventions become limited or the burden of medical treatment is deemed to outweigh the benefit. Family members and medical staff may have many misconceptions that a resuscitation order is not necessary until the child is viewed as ‘‘dying.’’ Regardless of the timing, DNR and do-notintubate orders have become increasingly complex. Although palliative care teams often teach primary providers the importance of recommending these orders to families, providers
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Fig. 1. Clinical decision making and palliative surgery. (From Ferrell BR, Chu DZJ, Wagman L, et al. Online exclusive: patient and surgeon decision making regarding surgery for advanced cancer. Oncol Nurs Forum 2003;30(6):E108; with permission).
often ask ‘‘what do you want us to do?’’ Parents are then faced with the terrible burden of having to choose care interventions, rather than agreeing to recommendations, discussing benefits and burdens, and carefully considering what options are most consistent with the goals of the child or family. When a surgical option is recommended to enhance the child’s comfort or quality of life, this issue becomes even further complicated for parents. Is surgery for symptom management or avoidance of symptoms anticipated? One definition of palliative surgery offered is ‘‘any invasive procedure in which the main intention is to mitigate physical symptoms in patients with incurable disease without causing premature death’’ [26]. The authors, however, qualify this definition further, warning that it may be impossible to know if a certain surgical procedure will hasten death. This definition refers to physical symptoms, not quality of life, because surgery is a physical action; it does not consider when curative surgery becomes palliative or when surgery is used for
prophylactic treatment. The authors have attempted a definition that is morally acceptable in all regards, while raising qualifications that may be morally acceptable but require further deliberation and attention. In a recent qualitative study, Ferrell and colleagues [27] found that surgeons report that symptoms were the motivation to consider surgery with the goal of symptom relief. However, although patients considered physical symptom relief primary, they were also influenced by the social impact of improving symptoms and the need to maintain hope. These researchers developed a helpful algorithm to assist clinical decision making when considering palliative surgery (see Fig. 1). Ethics in palliative care Sometimes families ask to ‘‘do everything possible,’’ but this may not be beneficial or helpful to the patient. When requests are made from families to do everything possible,
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physicians must tell them what this truly means and why, although medical technology abounds, it may not be possible or warranted for a particular patient [26]. Patient autonomy is a major focus of health care today, and many experts may believe that satisfying the wishes of patients and their relatives is important. However, palliative surgery should not be offered to meet emotional, existential, and psychological needs so that patients and their relatives do not feel caregivers have ‘‘given up’’ or lost hope [26]. Families may request that everything possible be done so that they have no regrets later, but futile or harmful treatment should not be offered to patients and their families. A patient’s rights and autonomy should be respected, and honest information is important [26]. Benevolence also includes compassion when caring for a patient who has a DNR order. Compassion and benevolence are necessary for caring for all patients, but health care workers must be aware that not all benevolent actions end in doing good [26]. To maintain the dignity of the patient and autonomy of the patient, patients and families must be involved in all discussions related to care and active in the decision making. When a decision is made to move from lifesustaining therapies to palliative care, patients should be involved in discussions and the decision-making processes. If able to participate in decision making, the patient’s wishes should take precedence over any wish that was expressed in a previously written advanced directive or decisions [28]. The decision making should be a shared process that considers the pros and cons of any palliative intervention and involves careful deliberation [29]. Time should not be considered when trying to determine the wishes of a patient who has a DNR order; it is important to do the right thing.
planned and hopeful outcome but also what resuscitative measures will be taken that meet the goals of the patient. These steps may include transferring the patient to another hospital, finding alternative team members, or requesting assistance from the hospital ethics committee [6].
Legal considerations
References
Physicians and hospitals have been sued because patients were resuscitated against their or the family’s wish [30]. To avoid this situation, clear communication should occur, with concise documentation of discussions between patients, family, and health care providers. Physicians must specifically document and communicate to all health care team members to ensure that patient wishes are understood and respected [30]. For operating room personnel, this discussion must include not only the surgical procedure
Summary The best quality of life described by patients and families is best accomplished with shared decision making among all involved [29]. No simple guidelines exist on how to care for patients who have DNR orders. Patient decisions should be made in a noncoercive environment and should be respected without any consequences to care [31]. Dignity must also be maintained and health care workers should try and stay impartial, even if staff know patients well [31]. Health care providers must accept the wishes and decisions of patients, and incorporate these into care. Discussions and clear documentation are important to complete before surgery. Patients can accept more responsibility for care given when all information is provided, questions are answered and time is offered to make an informed decision on DNR orders in the operating room [32]. This process must occur so that care providers and staff in the operating room are knowledgeable and agree to the care plan. Currently, DNR orders in the operating room that are procedure-driven outline what will not be done for the patient. Focusing on what will be done for the patient in the end stages of life who is hoping for a ‘‘good death’’ may be best [3]. Hospitals must develop policies and implement practices that support and respect the needs of patients who have a DNR order, and also those of the operating room staff.
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