Ethical Dilemmas Regarding Cardiac Resuscitation (2): DNR in the Operating Room

One dilemma over the years has regarded a request by the patient not to receive cardio-pulmonary resuscitation (DNR). The problem was that the patient had consented to surgery. Often, the patient’s clinical condition was that of a terminally ill patient, perhaps with cancer or organ failure, who needed the surgery for palliative reasons. That is: the surgery would accomplish something that would prevent pain and suffering for the patient in his/her last months or weeks. However, an essential part of all surgery performed by surgeons and anesthesiologists is to maintain the life of the patient during the surgery. It may not be obvious to the layperson, but whenever the anesthesiologist puts the patient to sleep with an anesthetic, the patients’ breathing and thus ventilation may become impaired or can cease and so patients are intubated and artificially ventilated, essentially on respiratory life-support, just to keep them asleep and alive.. Other life-support measures are also carried out in virtually all major surgeries including medication and fluids to maintain blood pressure, replacement of lost blood and medications to control heart rate and rhythm. If the patient had a cardiac arrest during surgery, surgeons have refused to stand by, do nothing, and let the patient die simply because a DNR order had been written. In a way this refusal was out of concern for the standard of professionalism of their specialty but also out of self-interest since the patient’s death would add an unnecessary death to the surgeon’s mortality statistics. So how could surgery be performed if a DNR remained in effect? It couldn’t since it was a very rare surgeon or anesthesiologist or surgical staff would think of accepting a DNR.

Finally, in recent years, after much consultation with physicians and staff, ethics committees and lawyers, hospital policies have been re-written to set some consensus protocols for carrying out needed surgery on a patient with a pre-surgery DNR. The protocols might describe that the patient and family must be informed, as part of the pre-operative consent, that during the time the patient is in the operating room and after surgery while awakening in the recovery room, including time the patient needs to be ventilated because of consequences of the operation, itself, the DNR is temporarily revoked to be later re-established. Although, probably not as common as this protocol for surgery, hospitals have also considered whether to suspend DNR orders for other procedures including radiology. Again, it represents self-interest of the profession not to allow a patient to die as a direct result of some procedure and not directly related to the patient’s underlying illness.

What do you think? If a patient directs the hospital and physician to “let me die” in the event of a cardiac or respiratory arrest regardless of the circumstances, is it right and ethical for them to follow the request? ..Maurice.