Is it ethical to refuse anesthesia to a patient with a Do Not Resuscitate (DNR) order who refuses resuscitation during a procedure?

Refusing Anesthesia to DNR Patients: Ethical Considerations

It is not ethical or proper to refuse anesthesia to a patient solely because they have a DNR order and refuse resuscitation during a procedure or surgery. 1

Understanding DNR Orders in the Perioperative Setting

The Association of Anaesthetists Clinical Practice Guidelines (2022) clearly addresses this issue with the following key points:

• Intra-operative cardiac arrest is generally rare, and when it occurs, survival rates are high due to:

  • Common causes being treatable and potentially reversible
  • Continuous monitoring and immediate detection/treatment 1

• It is usually appropriate to suspend a DNR recommendation during the perioperative period, but this requires:

  • Discussion and agreement with the patient
  • Clear explanation to the healthcare team 1

• The anaesthetist should ensure any temporary suspension of the recommendation has been discussed and agreed with the patient 1

Ethical Framework for Decision-Making

The ethical approach involves:

1. Early discussion with patients to ensure shared understanding about which perioperative treatments (including CPR) would be appropriate and desired 1

2. Clear documentation of the patient's values, preferences, wishes, and concerns about their care 1

3. Collaborative approach between anaesthetists and surgeons to explain risks and benefits of surgery, anaesthesia, and treatments 1

4. Seeking additional opinions if an anaesthetist believes they cannot facilitate a successful patient-centered outcome that satisfies the patient's wishes 1

Important Distinctions in Perioperative Care

The 2022 Association of Anaesthetists guidelines make important distinctions about interventions that are not considered equivalent to CPR:

• Giving chest compressions to expedite circulation of a drug in low cardiac output (distinct from cardiac arrest)
• Using drugs from the cardiac arrest algorithm to treat bradycardia, hypotension, or arrhythmia
• Using defibrillation for suddenly occurring arrhythmia 1

These distinctions should be explained to patients with DNR orders.

Practical Implementation

Organizations should:

1. Provide mandatory training related to advance care planning and resuscitation policies 1

2. Establish processes to ensure healthcare teams are aware of any advance decisions made by patients 1

3. Have clear procedures for documenting discussions and decisions in the patient's health record 1

4. Ensure decisions are shared at team briefings and can be reviewed/updated as necessary 1

Common Pitfalls to Avoid

• Misinterpreting DNR orders: A DNR order only limits specific resuscitative efforts and does not imply withholding other appropriate treatments 2

• Delayed or token efforts: So-called "slow-codes" (knowingly providing ineffective resuscitative efforts) are inappropriate and compromise ethical integrity 1

• Lack of documentation: Failing to document discussions about DNR status in the perioperative period can lead to confusion and errors in honoring patient wishes 3

• Making unilateral decisions: Refusing anesthesia without seeking additional opinions or exploring alternatives 1

Conclusion

Refusing anesthesia solely based on a patient's DNR status is not ethically justified. Instead, healthcare providers should engage in thorough discussion with patients about their wishes, clearly document these discussions, and develop a plan that respects patient autonomy while providing appropriate care during the perioperative period.