DNR Orders in the Periprocedural Period: Informed Consent and Refusal By Faith R. Protsman, MD Chair, SCCMA Bioethics Committee Do Not Resuscitate Orders in the perioperative/periprocedural period are often a source of difficulty and stress for physicians, staff, family members, and patients. With the intention of creating a workable plan that would offer guidance for this challenge, the SCCMA Bioethics Committee developed a “Model Policy for the Perioperative or Periprocedural Treatment of Patients with an Existing Do-Not-Resuscitate Order or Other Directives that may Limit Treatment During Invasive Procedures.” The members of this multidisciplinary committee include physicians, nurses, social workers, ethicists, and attorneys who worked to develop this policy over the past 18 months. Central to the debate of the issues involved is the concept of informed refusal. Informed refusal is a medico-legal term in which a person has the right to refuse a diagnostic or therapeutic intervention after gaining a full understanding of the risks and benefits of that intervention. Informed refusal is an integral part of the informed consent process. Informed consent laws are evolving to a patient-centric model. Federal requirements for informed consent are delineated in the CMS Conditions of Participation. This Condition of Participation provides that the patient has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. A physician must explain to the patient the risks, benefits, and alternatives for an intervention to allow that patient to make an informed decision about treatment. Adults who have decision-making capacity express their autonomy through the informed consent process. This autonomy is honored when physicians accept the patient’s informed decision, whether or not they consent to treatment. Without informed refusal, informed consent would simply be a patient’s acceptance of the physician’s recommendations. It has been common practice, in many institutions, to automatically suspend a DNR order during the perioperative/periprocedural period, as the process of anesthesia and effects of surgery can often produce physi36 | THE BULLETIN | SEPTEMBER / OCTOBER 2013
ologic changes of cardiopulmonary dysfunction or arrest. These effects are usually quickly and easily reversible, but utilize procedures that are considered resuscitative. This model policy offers direction and options for suspension of a DNR order and the length of the suspension, through the informed consent process. Richard J. Kramer, MD, shared a scenario that occurred just after he had received this policy for review: “We were presented with a patient recently at a local hospital in San Jose, who had hepatitis B, cirrhosis, and end-stage advanced hepatoma of the liver. He was discussed at a Liver Tumor Board, and it was felt that no treatment was left for the patient. He was, therefore, put on hospice. The patient decided that he wanted DNR/DNI status for any admissions. Subsequently, he was readmitted to the hospital during the night with hematemesis, likely from esophageal varices. The question of his DNR/DNI status clearly arose, and the decision was whether to endoscope the patient and try to stop the bleeding or not. Having seen the proposed policy by the Medical Association about this issue, we discussed the situation with the patient and his family. The patient was still lucid and capable of decision making. He verbalized the desire to attend a family event during the next two-to-three weeks and, despite his DNR/DNI status, he decided he wanted the endoscopy done, understanding that we might be able to temporize his situation by stopping the bleeding. He was clear with us that if something happened during the procedure, his DNR/DNI wishes still stood, but that if we could get him through this time, he preferred it. He fully understood that if he arrested during the procedure, that he would not want anything done. With this in mind, we wrote a note on the chart documenting this decision, the discussion with the patient and family, and the guidelines we would follow. All were in agreement, so we proceeded to endoscopy, stopped the variceal bleeding, and the patient was able to do what he needed to do. Unfortunately, he did expire within one-to-two weeks after this episode, but he and the family were happy with how we proceeded. I would like to extend my sincere appreciation to all members of the SCCMA Bioethics Committee for their dedication and diligence in the creation of this policy.”