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By D. W. DONOVAN, D.BIOETHICS, MA, MS, BCC ver since cardiopulmonary resuscitation (CPR) was developed in the mid-20th cen - tury, it has held a unique place in American medicine as the single major medical inter - vention for which consent is presumed rather than required. E That presumption is strongly embedded in the culture of American medicine. Only the request of a patient can overturn it, and only if the request is confirmed by a “Do Not Resuscitate” (DNR) order from a licensed independent provider. In those cases, the patient, or his or her surrogate decision-maker, has taken the proper steps to notify the treatment team that it no longer has permission to attempt resuscitation. However, the strength of the pre - sumption in favor of CPR occasion - ally has led medical staff to deter - mine that a DNR order should be ignored — that is, “suspended” — in certain circumstances, without additional conversation with the patient or surrogate. This tendency has been par - ticularly prevalent in the operating room, where the practice of suspending DNR orders is not uncommon.

POSITION STATEMENTS Statements by the American Society of Anesthe - siologists, 1 the American College of Surgeons, 2 the American Association of Nurse Anesthetists, 3 and the Association of periOperative Registered Nurses 4 agree that the unilateral discontinuation or suspension of DNR orders in the periopera - tive setting — that is, the time period encompass - ing a patient’s preparation for surgery, the surgi - cal procedure and post-operative recovery from anesthesia — is inconsistent with the Patient Self- Determination Act of 1992 and a patient-centered ethic of respect for patient autonomy. The Ethical and Religious Directives for Catho - lic Health Care Services , specifically directives 26 and 27, say a patient or surrogate must give “free and informed consent” for medical treatments and procedures, “except in an emergency situa - tion when consent cannot be obtained and there is no indication that the patient would refuse con - sent to the treatment.” 5 Thus, unilaterally suspending DNR orders in the operating room is inconsistent with Catholic health care’s collective value of respect for the person and the principle of autonomy, as well as being detrimental to a culture of patient-centered care. But if the “suspension” practice is to end, a system or medical center must ensure that three elements are in place to support such a change in practice: The facility has a “required review” policy. DNR orders cannot be unilaterally discontin - Is It Ethical to Suspend A DNR Order in Surgery? The strength of the presumption in favor of CPR occasionally has led medical staff to determine that a DNR order should be ignored in certain circumstances. PATIENT AUTONOMY HEALTH PROGRESS www.chausa.org JULY - AUGUST 2015 63 JULY - AUGUST 2015 www.chausa.org HEALTH PROGRESS 64 ued in the perioperative setting. Training must explain the ethical rationale and the requirement for detailed conversations with patients or their surrogates before surgery. Staff must understand clearly the legal nuances of DNR orders and their implications The policy gives providers who have ethi - cally sound reasons the option to recuse them - selves from participation in a patient’s DNR order ETHICAL RATIONALE Here is a hypothetical case that shows how com - plicated and confusing DNR circumstances can get: Mr. Jones is a 65-year-old patient who has end- stage kidney disease. Two weeks ago, his doctor told him he had about six months left to live and invited him to discuss his options for that period of time. Mr. Jones decided he was willing to con - tinue his biweekly dialysis treatments, but he did not want to escalate care and he didn’t want to go to the hospital. Mr. Jones made preliminary arrangements for hospice care and signed an out- of-hospital DNR order. Outside his dialysis center the following week, Mr. Jones was struck by a bus. The bus driver immediately began CPR, but when the ambulance arrived, the EMS squad saw Mr. Jones’ authorized DNR bracelet and interrupted the bus driver’s efforts. The bus driver objected, concerned about a manslaughter charge, and he argued that they should make every effort to resuscitate Mr. Jones. “For God’s sake,” the driver shouted, pointing to the dialysis center ID Mr. Jones was still wear - ing, “the man just walked out of a dialysis center.

He obviously still wanted treatment!” Though they understood the bus driver’s distress, the EMS crew explained that the DNR bracelet meant Mr. Jones had withdrawn consent to attempt resuscitation. Embedded in this case study are a number of issues that many operating room personnel would find familiar. The bus driver’s first reaction is to draw a distinction between the patient’s underly - ing disease (which the DNR order suggested he expected to die from) and the immediate cause of his cardiac or respiratory arrest — being hit by a bus. In a similar manner, anesthesiologists have argued that the principle of non-maleficence (do no harm) should be the overriding factor if anesthesia, not the patient’s underlying disease, directly causes a patient to stop breathing or for his or her heart to stop. 6 This is a valid concern and represents a true ethical dilemma: Which principle or value should be given greater weight in such a situation? This dilemma reinforces the need — before surgery — for a detailed conversation between the relevant providers and the patient (or surrogate) to discuss his or her wishes if there were a life- threatening turn of events in the oper - ating room. Otherwise, just as the bus driver did, members of the operating room staff may argue in all good con - science that the DNR can and should be unilaterally suspended because the patient wouldn’t have sought surgery in the first place if he or she did not wish to prolong his or her life. That’s not always true. A 1995 study demonstrated that 15 percent of patients with an existing DNR order do undergo surgical procedures, most often with a palliative focus. 7 Yet as our story about Mr. Jones illustrates, a willingness to engage in one form of treatment does not mean that there is a corre - sponding willingness to engage in a more invasive procedure. There could be any number of reasons a patient might agree to further treatment, even surgery, but be unwilling to have resuscitative efforts attempted. And a patient would have no reason to think his or her DNR order could be overruled in the operating room. While OR personnel may feel that a DNR order could be unilaterally suspended in the periopera - tive setting, particularly when they may feel “that it was their actions that led to the death of the patient,” the critical factor remains the right of the person to refuse an unwanted medical procedure. 8 To restate: Once a person has exercised the right to effectively reverse the presumption of consent to CPR or other lifesaving measures, then Anesthesiologists have argued that the principle of non-maleficence (do no harm) should be the overriding factor if anesthesia, not the patient’s underlying disease, directly causes a patient to stop breathing or for his or her heart to stop. respect for the person, a commitment to patient autonomy and a desire to form a patient-centered culture make an additional conversation with the patient ethically mandatory when a patient with a DNR order presents himself or herself for surgery.

POLICY AND PROCEDURE An appropriate medical center policy would state that a previously written DNR order remains in effect in the operating room or during a proce - dure unless clearly addressed beforehand. When a patient with a DNR order is scheduled for a pro - cedure, a physician involved with the procedure must discuss with the patient or his or her surro - gate decision-maker the possibility and implica - tions of discontinuing the DNR order. It is the responsibility of the patient or surro - gate to consider the risks, benefits and alterna - tives of the procedure, including the possibility of intraoperative cardiac or respiratory arrest (to be clearly distinguished from pre-arrest complica - tions and related interventions) and, under those circumstances, whether or not the patient wishes to have the DNR order revoked. The physician must put in the medical record both the discus - sion and any change in orders. As a general rule, a previously recorded DNR order cannot ethically be suspended or unilater - ally discontinued by a physician. Respect for the dignity of the human person, the principles of informed consent and patient autonomy require that the patient’s preferences be honored. UNDERSTANDING THE DNR ORDER A DNR order is a medical order by a licensed independent provider that resuscitative efforts should not be initiated in the unique event of car - diac or pulmonary arrest. A DNR order is written according to precise legal wording, and training will help staff differentiate between resuscitative efforts and pre-arrest interventions. Fortunately, most states have very similar wording related to DNR orders. While most clini - cians are familiar with the concept that “Do Not Resuscitate does not equal Do Not Treat,” few cli - nicians have a clear understanding of the implica - tions of this principle. Here is another hypothetical situation to help illustrate: Mrs. Smith is in the hospital. She is a 75-year- old woman with a DNR order who begins to expe - rience severe difficulty breathing in the middle of the night, reflected in a reading of the oxygen lev - els of her blood dropping from the 90s to the 60s. In the absence of any other information, should she be intubated? It is easy to see why there might be some confu - sion around this issue. Sometimes we use a DNR order as the capstone to a comfort-care approach; sometimes we use a DNR order to draw a line in the sand, promising the family that we will con - tinue to treat the patient aggressively, but only up until the point of cardiac arrest. From a strictly legal perspective, the answer is simple. In the absence of any other orders, the HEALTH PROGRESS www.chausa.org JULY - AUGUST 2015 65 © sfam_photo JULY - AUGUST 2015 www.chausa.org HEALTH PROGRESS 66 patient should be intubated, because she has not experienced the unique event of cardiac or pulmo - nary arrest . The DNR order becomes operative in the most immediate sense only when this “trig - ger” has been met. So, while some of the same tools (such as the ventilator) might be used in var - ious situations, they are considered truly resusci - tative only when the patient has experienced car - diac or respiratory arrest. It is worth noting that the Physician Orders for Life-Sustaining Treatments (POLST) form, which has become popular in many states, clearly makes this differentiation. One set of orders (code status) is followed if the patient does not have a heartbeat or discernible breathing. The second order set (treatment limitations) is followed if the patient does have a heartbeat or discernible breathing. Making this important distinction clear is crit - ical to helping clinicians understand the very lim - ited scope of the DNR order. It is equally impor - tant that providers be able to explain these varia - tions to patients pre-operatively in order to assure truly informed consent. A clear understanding will reassure that anes - thesiologist that a sudden drop in blood pres - sure can be addressed without violating the DNR order, and that intubating the patient as a part of the procedure is both allowable and appropriate. Similarly, the patient needs to understand that his or her existing DNR order does not preclude the possibility of intubation (either in a planned fashion or emergently prior to arrest). Only a clear and honest conversation between provider and patient can ensure a mutual understanding of the possible outcomes, while honoring the rights of the patient and the clinician’s commitment to autonomy and patient-centered care.

SUGGESTED POLICY AND PROCEDURE Medical center policy should clearly distinguish between pre-arrest orders, which may include treatment limitations such as “Do Not Intubate” or “Avoid admission or transfer to Intensive Care Unit for escalation of care” and post-arrest orders, which include only the options to Attempt Resus - citation (Full Code) or Do Not Attempt Resuscita - tion (No Code). Note that a POLST form clearly makes this dis - tinction, consistent with state law. Remember that the code status order becomes operative in the most immediate sense only when the patient is in cardiac or pulmonary arrest. Orders limiting treatment prior to arrest should be clearly indicated. Affirming that “Do Not Resuscitate” does not mean or imply “Do Not Treat,” it is critical for staff to understand that all treatments and interven - tions are available to a patient with a DNR order until the point of cardiac or respiratory arrest. For example, it is possible for a patient with a DNR order to be intubated or to remain intubated. It is important to explore with the patient or surrogate decision-maker whether to enter addi - tional orders that place limits on the extent of life- sustaining measures to be employed in his or her care.

OPTION FOR RECUSAL Even with a clear articulation of the ethical ratio - nale for not suspending a DNR in a perioperative setting, and armed with a more complete under - standing of the DNR order itself and the limited circumstances in which it would become truly operational, situations will emerge in which a provider might find it ethically unacceptable to attempt surgery with a DNR order in place. To allow for such cases, and to increase the likelihood that providers are true partners in this initiative, it is critical to fully support them — par - ticularly anesthesiologists — if they choose not to participate in a particular procedure because they have a fundamental medical or ethical objection to doing so. Affirming that “Do Not Resuscitate” does not mean or imply “Do Not Treat,” it is critical for staff to understand that all treatments and interventions are available to a patient with a DNR order until the point of cardiac or respiratory arrest. The hypothetical example:

Ms. Johnson is a 46-year-old female with a his - tory of significant mental illness and multiple hospitalizations following suicide attempts. She retains decision-making capacity. She has devel - oped coronary artery disease, which has wors - ened, primarily due to inconsistent compliance in her pharmaceutical treatment regimen. A Coro - nary Artery Bypass Graft (CABG) now seems like the best option, but the patient refuses to undergo the procedure without a DNR order in place, stat - ing that if her heart were not to restart on its own, she wishes to be allowed to die. This case involves a procedure during which the heart is intentionally stopped in order for surgery to be performed. While the heart usually starts beating on its own following restoration of blood flow, it may require interventions that are resuscitative in nature to help it restart. Because of this possibility, it would be perfectly reason - able for a provider to refuse to participate in such a surgery if the patient were not willing to have her DNR order temporarily discontinued. The provider also might note a fear that she or he was being asked to participate in a variation of physi - cian-assisted suicide, given the patient’s mental history and the unusual nature of the request. Respect for the dignity of the human person, the principles of informed consent and patient autonomy require that we honor the resuscita - tion preferences expressed by the patient in such circumstances. A previously recorded DNR order cannot be suspended or unilaterally discontinued by a licensed independent provider. However, neither is the provider required to participate in a course of action that would vio - late his or her ethical or religious beliefs. In such a case, the provider may choose, in a nonjudgmen - tal fashion, to withdraw from the case.

IN SUMMARY Given that the practice of suspending DNR orders in the operating room often has been viewed as acceptable, efforts to change this mindset depend on strong leadership and a willingness to engage a variety of stakeholders in thoughtful conversation. The Catechism of the Catholic Church reminds us that “God created man a rational being, confer - ring on him the dignity of a person who can initi - ate and control his own actions. Freedom is the power ... to perform deliberate actions on one’s own responsibility.” This fundamental belief provides the theologi - cal foundation for patient-centered care. We have an opportunity to ensure that this shared value is honored everywhere, every time.

D. W. DONOVAN is vice president, mission, spiri - tual care, and ethics, for the Northwest Washing - ton Region of Providence Health and Services.

NOTES 1. American Society of Anesthesiologists, “Ethical Guidelines for the Anesthesia Care of Patients with Do- Not-Resuscitate Orders or Other Directives That Limit Treatment.” www.asahq.org/resources/ethics-and-professionalism 2. American College of Surgeons, “Statement on Advance Directives by Patients: ‘Do Not Resuscitate’ in the Operating Room.” https://www.facs.org/about-acs/ statements/19-advance-directives.

3. American Association of Nurse Anesthetists, “Anes - thesia Department Policy Regarding Advance Direc - tives.” www.aana.com/resources2/professionalprac - tice/Pages/Anesthesia-Department-Policy-Regarding- Advanced-Directives.aspx.

4. Association of periOperative Registered Nurses, “AORN Position Statement on Perioperative Care of Patients with Do-Not-Resuscitate or Allow-Natural- Death Orders.” www.aorn.org/Clinical_Practice/Posi - tion_Statements/Position_Statements.aspx.

5. See United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, Fifth Edition (Washington, D.C.: USCCB, 2009), Directive 26 and Directive 27.

6. Ukebu Iroha and Heidi Wilkerson, “Should ‘Do Not Resuscitate’ Orders Be Revoked Prior to a Patient Receiving an Anesthetic?’” sites.duke.edu/dukesls2014/files/2014/01/8-SLS-Advo - cacy-DNR.pdf.

7. Judith O. Margolis et al., “Do Not Resuscitate (DNR) Orders during Surgery: Ethical Foundations for Institu - tional Policies in the United States,” Anesthesia & Anal - gesia 80, no. 4 (1995): 806-9. http://journals.lww.com/anesthesia-analgesia/Full - text/1995/04000/Do_Not_Resuscitate__DNR__ Orders_During_Surgery_.27.aspx.

8. Cynthia B. Cohen and Peter J. Cohen, “Do-Not-Resus - citate Orders in the Operating Room,” New England Jour - nal of Medicine 325, no. 26 (1991): 1879-82. HEALTH PROGRESS www.chausa.org JULY - AUGUST 2015 67 Copyright ofHealth Progress isthe property ofCatholic HealthAssociation ofthe United States anditscontent maynotbecopied oremailed tomultiple sitesorposted toalistserv without thecopyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.