This Editorial View accompanies the following article: Truog RD, Waisel DB, Burns JP: DNR in the OR: A goal-directed approach. Anesthesiology 1999; 90:289-95.
On October 21, 1998, the American Society of Anesthesiologists' House of Delegates approved a revision of the Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders or Other Directives That Limit Treatment that added the third option of a goals- and values-directed approach. This revised document appears in the ASA Standards, Guidelines and Statements, dated October 1998. The full text for this appears on the ASA web site at the following address: www.asahq.org/standards
PASSAGE of the Patient Self-Determination Act in 1990 represented a response to public outcry against lingering authoritarianism and paternalism in the medical profession, a legacy of premodern medicine in which “arrogance”was both an integral element of the art of medicine and an expression of adherence to the bioethical principle of beneficence. This federal legislation recognized the emergence of respect for patient autonomy as the predominating principle in biomedical ethics, and it was specifically designed to ensure patient self-determination for decisions about life-sustaining therapy. In this issue of the Journal, Truog et al. recommend to anesthesiologists a practical approach for preserving the autonomy of the surgical patient with an existing do-not-resuscitate (DNR) order.
Autonomy refers to the patient's right to choose and act intentionally, with understanding, and devoid of controlling influences. In the practice of anesthesiology, this respect for patient self-determination is honored through the process of informed consent. The anesthesiologist's duty is to adhere to that which is mutually agreed on with the patient or their designated surrogate. Yet, well into this decade, the right to refuse life-sustaining therapy, even of terminally ill patients with existing DNR orders, was denied by the routine suspension of their DNR orders as they entered the operating room. Several seminal essays written by anesthesiologists challenged this customary breach of patient autonomy and called for reevaluation of this issue. [3-9]
The ensuing discussion was of such importance that the American Society of Anesthesiologists' (ASA) newly established Committee on Ethics addressed this issue as its first major project. After two years of deliberation the Committee recommended the Ethical Guidelines for the Anesthesia Care of Patients with Do Not Resuscitate Orders or Other Directives that Limit Treatment. These were adopted by the House of Delegates in 1993. The crux of the Guidelines was that there should be a required reconsideration and renegotiation of the patient's existing DNR directive. At the ASA's urging, the American College of Surgeons adopted a similar policy, as did the Association of Operating Room Nurses, thus establishing a cross-professional understanding of the continuing fundamental right of competent patients to define and limit what treatment will be provided to them in the operating room.
The Guidelines recommended two alternatives from which patients with an existing DNR status (or their surrogates) could choose during the daunting process of informed consent:(1) rescind the DNR order and permit an unrestrained attempt at resuscitation or (2) limit resuscitation with regard to certain procedures.
Despite widespread dissemination of the Guidelines, there was only lukewarm acceptance, frequent misunderstanding, and inconsistent application. In 1996, Bastron et al. responded to the Guidelines by describing a two-pronged decision process that their institution used for management of this patient population:(1) patients could choose to rescind their DNR status during the perioperative period or (2) patients could delegate all decisions regarding resuscitation procedures solely to the anesthesiologist. Although this approach claimed to offer patients a choice, some critics responded that, in fact, it represented no choice at all because either option resulted in anesthesiologists having a contract to do whatever they thought was best. The essence of respect for autonomy is to provide the patient with true choices and not merely the appearance of choice. This article nonetheless served as an invaluable focal point for further discussion.
Why is there a persistent ambiguity and ambivalence in our specialty regarding the care of patients with existing orders limiting resuscitation? What can be done to facilitate the appropriate management of these patients who have a moral right to make choices regarding their care, even when they conflict with a physician's desire to sustain life? Truog et al. address these questions, and then they recommend a third option to the informed-consent process that significantly expands the range of choices available to this patient population.
There are pragmatic and psychologic obstacles between physicians and their patients regarding agreements to limit resuscitation in the operating room. These include (1) the blurred distinction between the basic elements of anesthesia care and resuscitation;(2) the knowledge that the causes of the majority of prearrests (cardiovascular or respiratory instability, or both) and arrests are the result of anesthetic or surgical interventions, or both, and often are easily and completely reversible;(3) a psychologic reluctance to continue the DNR status-to invite death-into the operating theater ;(4) a misunderstanding of the medicolegal issues involved;(5) the discomfort and inexperience in discussing issues of death and dying with patients about whom they have limited knowledge and with whom anesthesiologists have only a nascent therapeutic relationship;(6) the inadequate quality and quantity of time for discussion with patients/surrogates because of the rushed atmosphere of the operating room; and (7) disagreements between caregivers and even among surrogates.
Truog et al. imply, but do not directly address, the fact that resuscitations in the operating room have a much more favorable prognosis than those elsewhere in the hospital. In fact, the original impetus for questioning the universal application of cardiopulmonary resuscitation for cardiac arrest in patients in the hospital was derived from studies showing only an 8-14% survival to discharge from in-hospital cardiopulmonary resuscitation. [16,17]Some of these efforts were considered to be the equivalent of medical futility. On the contrary, there is more than 50% survival from cardiopulmonary resuscitation for operating room arrests. These rates best reflect the prognosis of the cause of the arrest, many of which can be traced to the anesthesia or to surgery rather than the patient's underlying terminal disease.
In negotiating the complex discussion of consent for resuscitation, one might invoke a pragmatic approach that centers on issues related to specific procedures. This procedure-directed approach is the recommended alternative to rescinding the DNR orders in the current (1993) Guidelines. It has the advantage of avoiding ambiguities by precisely describing which resuscitation functions are to be permitted. However, procedure-directed approaches do not address the contextual issues of an arrest or the patient's desired outcome.
The third option proposed by Truog et al. is a goal-directed approach. It is one in which the anesthesiologist tries to ascertain the patient's goals, objectives, and values for care to hold them as the primary consideration in the event of an arrest. This goals-directed approach has advantages over the procedure-directed approach: the anesthesiologist is given more procedural flexibility, and the context of the arrest plays a larger role in determining the clinical response it generates.
But, goal-directed approaches have some distinct pragmatic and ethical requisites. Having to understand a patient's goals, values, and objectives is a challenging obligation. [13,14]It mandates establishing a meaningful physician-patient relationship that is appropriate to arriving at a reasonable understanding of the patient's intentions. It demands that this relationship then procedures the required trust by the patient of the anesthesiologist for making clinical judgments and decisions that best reflect the patient's desires. This covenant of trust mandates sincerity of intent in a relationship that inherently is disadvantageously unbalanced for the patient with regard to power and vulnerability. Because of the usual limitations of clinical practicalities, is it possible to achieve a level of intimacy, understanding, loyalty, and trust that would be suitable to the task?
Another mundane, but temporally burdensome, demand imposed by the goal-directed approach is the explanatory narrative documentation of the informed-consent process.
Ethically, one must at least question whether the principle of respect for patient autonomy is best served by a process that introduces, rather than eliminates, ambiguities in decisions about therapeutic interventions. Although Truog et al. suggest at one point in their article that DNR orders should be as specific as possible to minimize “the requirements for subtle judgments and prognostication,” a goals-directed approach is the ultimate in ambiguity. In their own words, “the patient ultimately agrees to trust the surgeon [and in this case, the anesthesiologist] to use his or her best judgment, depending upon what is called for at the time and under the circumstance.” Is it wise to permit physicians to serve as surrogate decision-makers for patients when we know that they tend to be especially poor in this role?Even Truog et al. point out that when quality-of-life issues are being addressed physicians are more likely to deviate from the patient's preferences. When studied, physicians were incorrect in predicting resuscitation wishes in 24% of their patients. Even more interesting, physicians were not more likely to accurately predict patients' wishes even after they had discussed preferences with their patients. Furthermore, interventions to improve communication about end-of-life issues between patients and physicians did not change prediction accuracy.
It is ironic that we have, in a way, come full circle. Originally DNR orders evolved to take resuscitation decisions away from doctors and give them back to patients. Yet a goals-directed approach has the risk of returning the decision making to the physician. A real concern is that many physicians may interpret this new “choice” as carte blanche to do whatever they wish, so long as it appears to be consistent with some loosely interpreted version of the patient's “goals.” Indeed, this approach could be used as a ruse for an intentional manipulation of the informed-consent process to effectively rescind the existing DNR order. Ultimately, patients must rely on the moral and ethical integrity of their anesthesiologist.
In conclusion, the goal-directed option espoused by Truog et al. has its own set of potential problems and limitations. Yet it creates a tripartite set of choices that enhances the flexibility and practicability sought in the management of this ethically perplexing patient population. We physicians have a duty to pattern our responses to each individual patient's needs by being compassionately respectful of their unique intentions and preferences.
It seems likely, given the individual and special nature of the physician-patient relationship, that no one set of choices for treating patients with orders limiting care will suffice to cover the complexities of the decisions involved. On the one hand, patients require-and the principles of ethical medical care demand-that we as physicians disregard many of our personal values to support decisions made by our patients. Patients want concrete reassurances that their wishes are understood, respected, and followed to the best of our abilities. On the other hand, the complexity of medical care decision making must also use the physician's professional judgments, lest we become mere technicians in an exercise of patient autonomy that fails to meet the medical or personal goals of either party.
Medicine is, at its center, a moral vocation grounded in a patient-physician covenant of trust. Anesthesiologists must achieve standards of clinical excellence to obtain practice privileges, but we may never be compelled to demonstrate proficiency in ethical reasoning or introspection. As such, knowledge and comfort regarding clinical bioethics becomes a matter of conscience and of personal and professional integrity.
Stephen H. Jackson, M.D.
Department of Anesthesiology; Good Samaritan Hospital; San Jose, California
Gail A. Van Norman, M.D.
Assistant Professor of Anesthesiology; Department of Anesthesiology; Division of Cardiothoracic Anesthesia; University of Washington; Seattle, Washington;firstname.lastname@example.org