Case 85 - DNR

Question 1

patient comes for surgery, has a pre-op DNR order, do you suspend it for surgery?

Answer 1

NO

Talk to surgeon, patient, and family about options regarding resuscication efforts in the OR

Question 2

what should you discuss with the patient and or patient’s surrogate before admin of anesthesia in a DNR patient coming for surgery?

Answer 2

1) discuss with family patient’s goals and wishes
2) anesthesia is an alternate state

• in which many negative physiological effecs can occur due to anesthesia and can be reversed:
  
  • hypotension, high spinal

3) highlight which procedures are essential for anesthesia and surgery, and which are not:
* chest compression, defibrilation, tracheal intubation, admin of resuscitave meds, use of O2, invasive monitoring, bag/mask ventilation
4) discuss when to reinstitute prior DNR/DNI status

Question 3

what course of action can be taken if anesthesiologist and patient or surgeon cannot come to an agreement?

Answer 3

1) withdraw from case after finding replacement
* anesthesiologist who has conflicting views of his or her morall views can withdraw from case after obtaining a replacement to provide care
2) if elective surgery, contact ethics committee
3) if emergent surgery and no replacement found

• original anesthesiologist must proceed with resonable adherence to patient’s directives
• explain risks of limiting care: such as death