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DNR Orders in the Periprocedural Period, continued from page 37 DNAR order to remain in place throughout the periprocedural period, according to the above guidelines. • SPECIAL CONSIDERATION: PATIENTS WITH SEVERE CARDIAC DISEASE UNDERGOING INVASIVE CARDIAC PROCEDURES The risk of invasive cardiac (or, at times, pulmonary) surgery is high; the cardiothoracic surgeons can ask permission that their services not be limited until a realistic estimate of prognosis is established, and then are executed in accordance with the above guidelines. Any clarification or modifications made to the patient’s directive should be documented in the medical record. In cases where the patient or designated surrogate requests that the anesthesiologist or surgeon/ proceduralist use clinical judgment in determining which resuscitation procedures may become appropriate, the anesthesiologist or surgeon/proceduralist should document the discussion with specific reference to the goals and values of the patient. Plans for postoperative care should indicate if or when the suspended directive to limit the use of resuscitative procedures will be reinstated. This generally occurs when the patient has recovered from the acute effects of anesthesia and surgery/procedure. Consideration should be given to whether continuing to provide the patient with a time-limited postoperative/procedural trial of therapy would help the patient or surrogate better evaluate whether continued therapy would be consistent with the patient’s goals and values. Concurrence on these issues by the primary physician, the surgeon/ proceduralist, and the anesthesiologist is desirable. If possible, these physicians should meet together with the patient or surrogate when these issues are discussed. This duty of the patient’s physicians is deemed to be of such importance that it should not be delegated. Other members of the health care team who are directly involved with the patient’s care during the planned procedure should, if feasible, be included in this process.

V. CONFLICT RESOLUTION

Should conflicts arise, the following resolution processes are recommended: • When a member of the medical team finds either the patient’s or another member of the team’s limitation of intervention decisions to be irreconcilable with his/her own moral views, then this member should withdraw in a nonjudgmental fashion, providing in timely fashion an alternative for care. • If a member of the medical team finds the patient’s or another member of the team’s limitation of intervention decisions to be in conflict with generally accepted standards of care, ethical practice, or institutional policies, then this member should voice such concerns and present the situation to the appropriate institutional body. A liaison should be established among representatives from the hospital’s anesthesiology, surgery/proceduralist, and nursing services for presentation, discussion, acceptance, and application of this policy/guidelines. Hospital staff should be made aware of the proceedings of these discussions and the motivation for them. Modification of this policy may be appropriate in emergency situations involving patients who lack capacity to make their own medical decisions and whose intentions beyond that of resuscitation efforts have not been previously expressed.

38 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

References

1. DNR in the OR: A Goal-directed Approach. Robert D. Truog, David B. Waisel, Jeffrey P. Burns. Anesthesiology 1999; 90:289295. 2. Do Not Resuscitate in the Operating Room: More Than Rights and Wrongs. Perry G. Fine, MD and Stephen H. Jackson, MD. American Journal of Anesthesiology 1995;22:45-51. 3. Ethical Guidelines for the Anesthesia Care of Patients With Do-Not-Resuscitate Orders or Other Directives That Limit Treatment. Committee on Ethics, American Society of Anesthesiologists House of Delegates statement originally published 1993, revised October 17, 2001, and last affirmed October 22, 2008. 4. Goals- and Values-directed Approach to Informed Consent in the “DNR” Patient Presenting for Surgery. Stephen Jackson MD and Gail Van Norman, MD, Anesthesiology, V90, No 1, Jan 1999. 5. Health Care Decisions Law CA, Probate Code Section 46004643 6. Informed Consent for the Patient With an Existing DNR Order. David B. Waisel and Robert D. Truog, MD. American Society of Anesthesiologists Newsletter 2001;65:13-14. 7. Perioperative Care of Patients With Do-Not-Resuscitate or All-Natural-Death Orders. AORN Position Statement, original approved by the House of Delegates March 1995, revision approved March 2009. 8. Statement on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room. American College of Surgeons. Bulletin of the American College of Surgeons, Vol. 79 No. 9, Page 29. Sept 1994.

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