Ethical Considerations with DNR Orders and Anesthesia Care

By Stacey Kusterbeck

Because many elements of anesthesia care constitute “resuscitation” in other settings, patients presenting for surgery with do-not-resuscitate (DNR) orders or other directives limiting treatment pose some unique ethical challenges. Traditionally, DNR orders simply were “reversed” during surgery.

“But growing attention to patient autonomy and the diversity of patient preferences have led professional societies to oppose automatic reversal,” says Matthew Allen, MD, assistant professor of anaesthesia at Brigham and Women’s Hospital. The American Society of Anesthesiologists, for example, opposes automatic reversal of DNR orders during the perioperative period in favor of a decision-making process that focuses on patients’ goals and clinical circumstances.

Anesthesiologists may struggle with how to translate goal-focused discussions into clinical plans, however. Allen and colleagues developed guidance for anesthesiologists in serious illness communication and decision-making.¹ “The nature of this decision-making process and associated guidelines have evolved over the last 30 years, alongside advance care planning in other contexts. We wanted to bring the existing literature into conversation with emerging frameworks for serious illness communication as a basis for addressing persistent challenges in perioperative decision making about CPR [cardiopulmonary resuscitation],” says Allen.

The authors advocate for approaches that focus on patients’ goals and clinical circumstances, rather than centering on existing code status or specific procedures. Ideally, the discussion starts with an understanding of the goals of a procedure in the context of a patient’s broader priorities, and how elements of anesthesia care may promote or undermine them.

“Nobody ‘wants’ a breathing tube, but intubation is frequently an important part of safe anesthesia care. Nobody ‘wants’ to have electric shocks delivered to their chest. But, particularly while sedated or under anesthesia, informed patients may deem cardioversion and/or defibrillation appropriate to avoid morbidity or mortality,” explains Allen.

Patients at advanced stages of terminal illness often undergo procedures focused on improving or maintaining quality of life. Such patients often are at risk for major complications, including perioperative cardiac arrest. “But performing chest compressions may contravene a patient’s broader goals and lead to health states they would deem worse than death,” says Allen. For example, patients may have a prolonged intensive care unit stay, ventilator dependence, or severe neurological injury.

Anesthesiologists face significant time pressure and lack longitudinal relationships with patients. Lack of training and comfort with goals of care discussions are additional constraints. “On the one hand, these constraints suggest that anesthesiologists are not ideally positioned to have these kinds of conversations with patients. However, in many cases we are the only ones who do,” says Allen.

Surgeons, anesthesiologists, patients, and surrogates may face difficulty achieving consensus regarding perioperative code status. “Such disagreements sometimes reflect incomplete understanding of the nature of anesthesia care,” observes Allen.

For example, some procedures require intubation. Anesthesiologists may rightly insist on the need for intubation as a basis for providing safe anesthesia care. In contrast, some surgeons or anesthesiologists hold a traditional view that surgery and anesthesia require that all interventions (including chest compressions) need to be “on the table.”

“But this view is questionable for patients who face significant risks for mortality and morbidity following perioperative cardiac arrest, and whose care is rightly characterized as palliative,” says Allen.

When ethicists are consulting on cases involving perioperative decision-making about the appropriateness of CPR, it is important to draw attention to patients’ concerns, says Allen. That includes the patient’s motivation for undergoing a surgical procedure. A decision to undergo surgery should not necessarily imply a need for patients to be “full code” in all cases. “It is necessary to ensure adequate understanding among patients and surrogates about the nature of the interventions under consideration — the risks and expected level discomfort associated with interventions, and the consequences of forgoing them,” advises Allen.

Reference

1. Allen MB, Siddiqui S, Nwokolo O, et al. Reviewing ethical guidelines for the care of patients with do-not-resuscitate orders after 30 years: Rethinking our approach at a time of transition. Anesthesiology. 2024;141(3):584-597.