AORN Position Statement
Perioperative Care of Patients With Do-Not-Resuscitate (DNR) Orders
PREAMBLE
Nurses have a responsibility to uphold the rights of
patients.1 A patient with a do-not-resuscitate (DNR)
order may require surgical procedures and anesthesia management.
These procedures often are for palliative care, to relieve pain or
distress, to facilitate care, or to improve the patient's quality
of life. A DNR order should not mean that all treatment is stopped
and the need for medical and nursing care is eliminated, but rather
that the patient has made certain choices about end-of-life
decisions.2 A patient's rights do not stop at the
entrance to the operating room.3 Automatically
suspending a DNR order during surgery undermines a patient's right
to self-determination.4 Development of a policy related
to DNR orders in the operating room is supported by the Patient
Self-Determination Act,5 the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), the "AORN
explications for perioperative nursing,"6 and "The
patient care partnership: Understanding expectations, rights, and
responsibilities."7
POSITION STATEMENT
- Required reconsideration of DNR decisions with patients is an integral component of the care of patients undergoing surgery.8
- Required reconsideration of DNR decisions ensures that the risks and benefits of anesthesia and surgery are discussed by health care providers and patients or patients' surrogate decision makers before surgery.
GUIDELINES
Patient autonomy must be respected as the professional
responsibility of the health care team. The patient's physicians
are responsible for discussing and documenting issues with the
patient and/or family to determine whether the DNR order is to be
maintained or completely or partially suspended during anesthesia
and surgery. The discussion needs to describe potential
resuscitation efforts during surgery and whether withholding
resuscitation compromises the patient's basic objectives for
surgery.9 Discussion involved with the required
reconsideration should include
- the goals of the surgical treatment,
- the possibility of resuscitative measures,
- a description of what these measures include, and
- possible outcomes with and without resuscitation.
If the patient has chosen to suspend the DNR order during the intraoperative period, it should be documented when the DNR order is to be reinstated.
Preoperatively, communication among the health care team, the patient, and the patient's family about DNR decisions must occur. Adequate information must be given so the surgical team supports the patient's or the patient's surrogate's right to participate in the health care decision.2 A method of communication needs to be developed so that all health care team members are informed of the patient's decision. Following the discussion, the decision and plan must be clearly documented and communicated to all health care providers potentially involved in the perioperative care of the patient. Throughout the process, the patient has the right to modify any decision, and this also must be communicated to all involved health care providers. Patient situations that may require further ethical deliberation before surgical intervention may benefit from consultation with the hospital's ethics advisory committee.
The perioperative nurse, as a patient advocate, has a moral responsibility to the patient. If the perioperative nurse has a moral objection to the patient's decision, he or she should be allowed to make a reasonable effort to find another nurse willing to provide care to the patient. If another nurse is not available, the patient's decision will be upheld, recognizing that there are times when a patient's wishes take precedence in a clinical situation.
OPERATIONAL DEFINITIONS
The following are operational definitions of terms used in
the statement.
Do-not-resuscitate (DNR) order. A specific directive, written by a physician, mandating that cardiopulmonary resuscitation should not be performed.8
Do-not-resuscitate (DNR) decision. The patient's or surrogate's directives regarding end-of-life choices.
Required reconsideration. An event that allows a patient or surrogate to participate in decisions about the use of cardiopulmonary resuscitation and that offers caregivers an opportunity to explain the significance of cardiac arrest and resuscitation in the perioperative setting.
Health care team. Nurses, physicians, and all others involved in clinical disciplines.
References
1. S Igoe, S Cascella, K Stockdale, "Ethics in the OR:
DNR and patient autonomy," Nursing Management 24
(September 1993) 112A, 112D, 112H.
2. J M Reeder, "Do-not-resuscitate orders in the operating
room," AORN Journal 57 (April 1993) 947-951.
3. S J Youngner, H F Cascorbi, J M Shuck, "DNR in the
operating room: Not really a paradox," Journal of the American
Medical Association 266 (November 1991) 2433-2434.
4. Igoe, Cascella, Stockdale, "Ethics in the OR: DNR and
patient autonomy," 112A, 112D, 112H.
5. Patient Self-Determination Act, Public Law
101-508, Federal Register 57 (March 6, 1992).
6. "AORN explications for perioperative nursing," in
Standards, Recommended Practices, and Guidelines (Denver:
AORN, Inc, 2004) 53-83.
7. American Hospital Association, "The patient care
partnership: Understanding expectations, rights, and
responsibilities,"
http://www.hospitalconnect.com/aha/ptcommunication/partnership/index.html
(accessed 23 November 2004).
8. C B Cohen, P J Cohen, "Required reconsideration of
'do-not-resuscitate' orders in the operating room and certain other
treatment settings," Law, Medicine & Health Care 20
(Winter 1992) 354-363.
9. R D Truog, D B Waisel, J P Bruns, "DNR in the OR: A
goal-directed approach," Anesthesiology 90 (January 1999)
289-295.
Resources
American College of Surgeons. "Statement of the American
College of Surgeons on advance directives by patients: 'Do Not
Resuscitate' in the operating room." ACS Bulletin 79
(September 1994) 29.
American Nurses Association. ANA Position Statement, "Nursing care
and do-not-resuscitate (DNR) decisions,"
http://nursingworld.org/readroom/position/ethics/etdnr.htm#DNR
(accessed 4 January 2005).
American Society of Anesthesiologists. "Ethical guidelines for the
anesthesia care of patients with do-not-resuscitate orders or other
directives that limit treatment,"
http://www.asahq.org/publicationsAndServices/standards/09.html
(accessed 4 January 2005)
Submitted: March 1995; Adopted: March 1995
House of Delegates, Atlanta, Georgia
Reaffirmed: October 1999, December 2004
Sunset review: December 2009