The Department of Health should consider amending the Regulations Governing Durable Do Not Resuscitate Orders (12 VAC 5-66) to clarify how the regulations apply to situations where there is a "required reconsideration" of a DNR during surgery or procedures.  Over the past twenty years, consensus has emerged from several professional societies on how best to respond to patients with active DNR orders who might benefit from surgery and related interventions.  Additional background on required reconsiderations and professional society positions is provided below.

Background:

Many patients at the end of life often would benefit from some surgery or other procedures to improve their quality of life.  While it is not unreasonable to presume that most patients would want all possible resuscitative efforts if they were to suffer a cardiac or pulmonary arrest during a surgery or procedure, this cannot be presumed for patients who have a DNR order in place. Such patients, who have a documented acceptance of allowing natural death, may prefer to forego resuscitative efforts even in the context of a surgery or procedure where the cause of arrest is potentially reversible.

Professional Society Positions:

ASA, ACS, AAP and others all endorse what referred to as “required reconsideration.” In brief, required reconsideration is the expectation that prior to undergoing a surgery or procedure where cardiac or pulmonary arrest is possible, the treating team will discuss with the patient or his/her surrogate what risks are associated with the procedure as well as what resuscitative measures the patient/surrogate consider most appropriate given the patient’s treatment goals and values. The final determination of whether/which resuscitative measures will be allowed should be the result of a mutually agreed upon plan between the team and the patient/surrogate, and should be clearly documented in the medical record, along with any corresponding decision as to when (if applicable) to reinstate the DNR.

American Society of Anesthesiologists (ASA): "Policies automatically suspending DNR orders or other directives that limit treatment prior to procedures involving anesthetic care may not sufficiently address a patient’s rights to self-determination in a responsible and ethical manner. Such policies, if they exist, should be reviewed and revised..."[i]

American College of Surgeons (ACS): "Policies that lead…to disregarding or automatically cancelling [DNR] orders do not sufficiently support a patient’s right to self-determination."[ii]

American Medical Association (AMA): Physicians should “[r]evisit and revise decisions about resuscitation—with appropriate documentation in the medical record—as the patient’s clinical circumstances change. Confirm whether the patient wants the DNAR order to remain in effect when obtaining consent for surgical or other interventions that carry a known risk for cardiopulmonary arrest and adhere to those wishes.”[iii]

Association of periOperative Registered Nurses (AORN): "Automatically suspending a do-not-resuscitate or allow-natural-death order during surgery undermines a patient’s right to self-determination."[iv]

American Academy of Pediatrics (AAP): “Because surgeons and anesthesiologists are rarely involved in the original DNR decision, they cannot be certain that the implications of the DNR status in the perioperative setting were discussed with the patient's parent (or other surrogate). Therefore, the parent or surrogate, the surgeon, and the anesthesiologist should reevaluate the DNR order for a child who requires an operative procedure. This reevaluation process has been called “required reconsideration” and should be incorporated into the process of informed consent for surgery and anesthesia.”[v]

American Society of PeriAnesthesia Nurses (ASPAN): “Assuming the patient’s wishes or applying an institutional policy or medical decision that automatically suspends any patient’s DNR, DNAR, DNI or AND directive during the perioperative period denies the patient’s right to self-determination and to autonomous, informed choices.”[vi]

American Association of Nurse Anesthetists (AANA): “For a patient undergoing anesthesia, reconsideration of the advance directive is an important part of the informed consent process.”[vii]

American Nurses Association (ANA): “Patients undergoing surgery pose special considerations. Regarding suspension of DNR status during surgery, strong arguments have been made that seriously or terminally ill patients who consent to surgery do so because they desire functional or palliative effects…In that case, automatic suspension or automatic continuation of a DNR order cannot be justified...”[viii]