DNR in the OR: resuscitation as an operative risk

Article Abstract:

In the late 1970's, hospitals began adopting formal policies for situations in which patients are not resuscitated (revived after apparent death). Prior to this time, resuscitation was withheld from terminally ill patients on a secretive basis. Although most hospitals now have do-not-resuscitate (DNR) policies in place, one area that is usually overlooked is surgery. A terminally ill patient may wish to have a DNR order placed in his hospital chart, and may also chose to undergo palliative surgery to relieve an obstruction or control pain. The status of the DNR order when a terminal patient undergoes surgery is sometimes not clear. Most medical orders are stopped by the surgeon just prior to surgery, and then rewritten after surgery; the question of whether this should apply to DNR orders is not as straight-forward. If they are rescinded, the patient may not wish to undergo the surgery if he will be resuscitated against his will; if they are honored, the surgeon may have to accept an avoidable intra-operative death. This problem has been overlooked by many DNR policies. The author argues that DNR orders should be honored during surgery. It is his view that the patient's right to not be resuscitated outweighs the surgeon's concern about avoidable surgical deaths. The surgeon should note that: the patient has accepted the risks of surgery; the situation is similar to a patient refusing blood transfusion on religious grounds; if death occurs, it is the negative result of a positive act (palliative surgery); and this is not the same as assisted suicide. Suggested policy guidelines for DNR orders for the operating room are presented. (Consumer Summary produced by Reliance Medical Information, Inc.)

Usage, Resuscitation

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DNR in the operating room: not really a paradox

Article Abstract:

It has taken 20 years for do-not-resuscitate (DNR) orders to become a standard of care nationwide. The existence of this type of order acknowledges not only that resuscitation may offer no benefit to the patient, but that a competent patient has a right to refuse resuscitation. Resuscitation status must be discussed by the physician with the patient and his family. An article in the November 6, 1991 issue of the Journal of the American Medical Association focuses on an important area in which the status of the DNR order is unclear. It is noted that an DNR order for some patients is not incompatible with receiving other types of care, such as palliative surgery to reduce pain. A DNR order creates a unique situation for the surgeon and anesthesiologist. It might appear that the standard of care is lowered, and the surgeon is asked to operate with 'one hand tied'. However, a patient's rights do not end at the door of the operating room. It is understandable that no surgeon wants to have a 'bad outcome'. Surgical deaths are often categorized as either expected or unexpected; patients with a DNR order usually would fall into the expected death group. Assessment of the quality of care given during surgery has to take into account a patient's refusal of resuscitation. The distinction between maintaining homeostasis (such as providing adequate fluids and controlling blood loss), which should be continued, and resuscitating the patient is important to make. Policy guidelines are suggested, which will require careful discussion, planning, and coordination; however, every hospital must answer the challenge and establish a policy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Editorial

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Impact of Hospital Volume on Operative Mortality for Major Cancer Surgery

Article Abstract:

High-volume hospitals may have lower mortality rates than low-volume hospitals following surgical treatment of cancer. Researchers compared survival statistics in the care of 5,013 elderly patients who underwent pancreatic, liver, esophageal, or other cancer surgeries. In all studied surgeries except for lung removal, the mortality rate was higher in low-volume hospitals. Following esophagectomy, 17% of patients in low-volume hospitals died, compared to only 3% of patients in high-volume hospitals. Staff at high-volume facilities may develop the skills and experience associated with a lower risk of patient death.

Evaluation, Mortality, Complications and side effects, Risk factors, Hospitals, Postoperative complications, Cancer

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