Vital Times 2014 - (Page 64)
THE ETHICAL CONSULTANT
Perioperative
'Do Not Resuscitate' Orders
By Stephen Jackson, MD, Editor Emeritus, CSA Bulletin
Case Presentation
A 90-year-old woman is
brought to the emergency
department from a nursing
home with severe pain in her
hip, controllable only with
large doses of narcotics that
quickly have induced somnolence and decreased oxygen
saturation. She has had a decade-long progression from
moderate to severe dementia. For the past year she has
been bedridden and unable to recognize or interact with
her family.
Her only child has the durable power of attorney for health
care and signed consent for a "Do Not Resuscitate" (DNR)
order. A hip fracture is identified, and an orthopedic
surgeon recommends pinning it as the safest way to
control her pain as well as offering the best chance to
return her to a nursing home.
The daughter agrees to the operation, but tells the
anesthesiologist that she will not agree to suspend the
DNR order. She will consent to a goals- and objectivesoriented limitation of attempts at resuscitation. However,
the surgeon refuses to perform the operation unless the
DNR orders are fully suspended.
What is the anesthesiologist to do?
64 | CSA Vital Times
Introduction
In 1991, anesthesiologist Robert Truog, MD, criticized the
customary automatic suspension of existing DNR orders
for patients who were to undergo anesthesia and surgery or
an invasive procedure.1 The1990 United States Patient Self
Determination Act, a response to the medical profession's
authoritarianism regarding decisions about life-sustaining
therapies, declared that patients have the right to consent
and to refuse medical therapy.
DNR orders are based on the concept that patients (or
their surrogates) may choose to forgo certain resuscitative
procedures - and their possible benefits - because they
reject the possible burdens associated with them. These
burdens may be related to the resuscitation attempt
itself (as with fractured ribs), or to the loss of functional
or cognitive capacity that may follow a "successful"
resuscitation.
Note that this federal law focused on a patient's right
to refuse medical treatment, including life-sustaining
therapy, tacitly recognizing that without informed refusal,
there can be no informed consent.2,3 A DNR order is
a medical and legal document that reflects a patient's
decision and desire to reject life-sustaining interventions.
The early 1990's anesthesia literature began to host a nearly
unanimous view that automatic suspension of DNR orders
could not be ethically justified.4-15
Table of Contents for the Digital Edition of Vital Times 2014
AND NOW, A WORD FROM THE EDITOR
PRESIDENT’S PAGE
ON YOUR BEHALF: CSA Fights and Wins in 2014
ADAPT AND PROSPER: A Guide to Survival
POLITICS AND MEDICATION SAFETY: The CSA 2014 Annual Anesthesia Meeting
DR. CSA GOES TO WASHINGTON
CALIFORNIA ANESTHESIA RESIDENCY IN 2014
A NEW YEAR AND NEW LEADERSHIP IN THE CSA
CAUTIOUSLY OPTIMISTIC – CSA FINANCES IN OUR 2014-15 FISCAL YEAR
THE ASA ANNUAL BOARD OF DIRECTORS’ MEETING: Building for the Future
ANESTHESIOLOGY™ 2014
CONSOLIDATION IN THE HEALTHCARE MARKETPLACE: What’s in your Future?
IF I COULD SPEAK
PEERING OVER THE ETHER SCREEN: Germs and the Pseudoscience of Quality Improvement
THE ETHICAL CONSULTANT: Perioperative ‘Do Not Resuscitate’ Orders
THE VALUE OF CSA MEMBERSHIP
UPCOMING MEETINGS
MY WEEK ON HAWAII'S BIG ISLAND
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