Increasingly, surgeons, anesthesiologists, and nurses are confronted with the request to operate on patients with preexisting “Do Not Resuscitate” (DNR) orders (see Framing Case, later in this article). There is much uncertainty and confusion regarding the proper approach to managing advance directives for these patients. Many believe that DNR orders must be suspended before an operation, and there is concern that clinicians put themselves at risk when operating on a patient with an extant DNR order. There are both clinical and ethical reasons, in specific patients, to either suspend, or not suspend the DNR order in the perioperative period, and, most importantly, such decisions should be the subject of shared decision-making between surgeon and patient, or surrogate decision-makers. In this article, we describe the factors that contribute to these decisions, and current policy.
Current data on in-hospital cardiopulmonary resuscitation (CPR) are not much improved since the early work of Zoll and Lown and colleagues. Although approximately 40% of patients who undergo CPR in the hospital will have return of spontaneous circulation (ROSC), only 10% will survive to hospital discharge.5 Of those, only 25% will survive in excess of 5 years, and a significant percentage will be confined to chronic care facilities or have neurologic disabilities. Younger, previously healthy patients, those with witnessed arrest, and initial rhythm of ventricular fibrillation tend to do better.6,7 Nonetheless, the current public perception of CPR, fueled by TV medical dramas, is that it is frequently (or even usually) successful, allowing most patients to both survive and return to a normal neurologic status.
As noted, electrical defibrillation was initially proposed for a restricted group of rhythms and settings, such as cardiac arrest in the OR. Through the 1960s, however, with the development of more standardized techniques, CPR became routine therapy for any patient who died in hospital. To avoid confusion and distress as to which patients should or should not undergo CPR, the American Medical Association recommended in 1974 that decisions not to resuscitate be formally entered in patients’ progress notes and communicated to all attending staff. In 1976, the first proposed hospital policy regarding “orders not to resuscitate” was published.8 This policy pointed out the “growing concern that it may be inappropriate to apply technologic capabilities to the fullest extent in all cases and without limitation.” Rabkin and colleagues8 also pointed out that “it is the general policy of hospitals to act affirmatively to preserve the life of all patients, including persons who suffer from irreversible terminal illness,” and thus mandated attempts at resuscitation in all patients without a DNR order. This created the perverse situation in which resuscitation became the sole medical intervention requiring a written order, and usually patient consent, not to perform.
Attempts to resuscitate or re-animate the dead have been made since antiquity, with occasional success beginning in the eighteenth century. Modern approaches to reversing cardiac asystole or ventricular fibrillation date to the early 1950s, with external electrical pacing and alternating current defibrillation, followed a few years later by DC countershock. Careful reading of these publications reveals that although defibrillation successfully reversed the electrical anomaly, at least transiently, few patients survived to hospital discharge. Further, because there were inadequate techniques for effective ventilation and oxygenation, defibrillation was successful only when initiated soon after onset of the arrhythmia. For this reason, it was hypothesized that cardiac arrest in the operating room (OR), where there is continuous observation and monitoring of the patient, would be most amenable to defibrillation and a successful outcome.