QUESTION: I’m on the Medical Staff at two hospitals that have very different approaches to existing DNR orders when a patient is going to surgery. The first hospital automatically suspends the DNR order without either talking with the patient or his or her representative. The second hospital allows that patient or representative to continue the DNR order throughout the surgery. What’s going on?
ANSWER: Though not as common as before, we still find hospitals that have a policy which states that a DNR order will be automatically suspended for surgery, without getting the consent of the patient or his/her representative to this change. Sometimes this is a formal policy; other times, informal (but 100% followed). There are sound reasons to suspend a DNR order for surgery, but not without the patient’s consent.
There are three principal medical concerns usually raised in connection with the suspension of a DNR order during surgery. The use of general anesthesia in the surgery, to which the patient consented, involves the deliberate depression of vital systems, and can produce apnea, some degree of cardiovascular instability and other effects. The very nature of the anesthetic procedure thus may require resuscitative efforts. Separating anesthesia from resuscitation is somewhat difficult conceptually.
Second, there is a difference between a cardiorespiratory arrest that occurs spontaneously, and one that results from a therapeutic intervention. If operative or post-operative difficulties relate to the anesthesia or the surgical procedure involved, and not to the underlying illness, the suspension of the DNR order addresses these complications and provides the patient with an opportunity to recover from them.
Third, the suspension of the DNR order is meant to address concerns that the patient or patient’s representative might not appreciate the medical issues and factors involved in perioperative complications, and the value of resuscitating the patient during this period.
While all of these concerns have merit, no hospital policy should automatically suspend the DNR order without first obtaining the specific agreement of the patient or his/her representative. A DNR order properly obtained in the hospital requires the attending physician to have discussed the DNR order with the patient or the patient’s representative. Through that discussion, the physician and the patient or patient’s representative determine the scope of that DNR order. A policy which then suspends that DNR order without the specific agreement of the patient or patient’s representative is legally inappropriate. That approach likely conflicts with state law and well-developed law concerning a patient’s legal rights to forego medical treatment.
But what if the patient won’t agree to suspend the DNR order? If this conflict can’t be resolved, some physicians are simply not comfortable performing the surgery for the medical reasons described above. If that is the case, the physician should see if there is another surgeon who will work with that patient.
Interestingly, we just reviewed an anesthesia protocol that allows the patient to fully suspend his/her DNR order, create a specific limited suspension, or provide for no suspension or limitation of the order during the operation or procedure/recovery. What a change from the other practice!