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O P I N I O N

the OR-do Do-not-resuscitate orders in

they work for the patient? thics can be defined simply as doing the right thing, but the E difficulty lies in discerning

whose definition of the right thing should be used. Some authors maintain that ethics “is concerned with doing good and avoiding harm.”’ In the medical arena, ethics can have far reaching impli- cations. Nurses must remember to give care according to the pa- tient’s need and not the nurse’s perception of that need. Care never can be withheld or reduced because a caregiver believes the patient to be noncompliant, un- educated, or unworthy.

PATIENT AUTONOMY Autonomy, which is one of the

concepts of ethics, can be described as self-governing or the right to choose. After being accused of wrongdoing but before his trial, the Greek philosopher Socrates could have exiled himself and avoided the upcoming trial. He chose to remain in Athens, Greece, even though he knew death could be the consequence of his trial.’ History may argue that the trial was unethical because of the unjust verdict handed down, but Socrates was satisfied because he retained his autonomy and decision making during the trial and sentencing period.

Patient autonomy also can be defined as a respect or regard for per~onhood.~ This is the funda- mental ethical principle guiding the advance directives movement. The purpose of informed consent is to ensure that the patient has the

information necessary to make decisions that affect the care he or she receives. Advances in medical knowledge and science have allowed physicians and nurses to educate members of the public about early detection of disease, intensely manage chronic pain, and extend life beyond that which some philosophers may deem moral or ethical. With these com- plex courses of action comes a responsibility to ensure that patients are allowed to participate in the healing process so it works effectively.4 Nurses are particular- ly influenced by the concept of autonomy because they are required to provide medical aid with respect for the patient.’ By applying principles of equity, self- determination, and well-being, as well as autonomy, health care workers and patients can justify care decisions.b

THE RIGHT OF REFUSAL

pate in his or her own care includes the right to rehse treat- ment. This leads to the dilemma of the patient having a do-not- resuscitate (DNR) order in place when entering the perioperative setting. Should a DNR be sus- pended when a patient who is ter- minally ill undergoes a palliative surgical procedure for debulking a tumor or relieving an obstruction? If the DNR order is suspended. how soon after the procedure should it be reinstated? Institutions may have a policy outlining a process for such an event, but it

The right of a patient to partici-

often is vague and inexact, leaving room for discussion and decision.

Patients are taken to the OR for a number of reasons. Some of these include debridement to aid in the healing process, repair of fractures, or relieving an obstruc- tion and easing pain. If a patient dies in the OR, perioperative team members worry about their inability to help the individual, failure to save a life, and perhaps a future lawsuit. Should the patient or designated surrogate have the final say as to whether a DNR is continued in the surgical and postanesthesia care unit set- ting? Does the hospital own this liability?

One case that drew consider- able attention to this matter was Cruzan v Director of Missouri Department of Health. Nancy Cruzan was left in a persistent vegetative state by an automobile accident. She was kept alive through a feeding tube. and her parents wanted the tube removed. The case was taken before the US Supreme Court, where Chief Justice William H. Rehnquist, in the prevailing ruling in 1990, maintained that although the deci- sion to choose between life and death is deeply personal with obvious overwhelming finality, the state legitimately could con- tinue to protect the life of Cmzan. Justice William J. Brennan, Jr, in his dissenting statement said that the patient “is entitled to choose to die with dignity.”’ Therein lies an ethical dilemma. Who is right and who is wrong?

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In years past, it was under- stood that a DNR was suspended automatically when a patient entered the OR. Patients and their family members had little if any choice in deciding when to sus- pend and reinstate a DNR. Patients today, however, demand more decision-making ability about the care given to them, as well as greater accountability from health care providers. Information on detecting symp- toms of early disease and avail- able treatments is accessible readily through the present day media. Patients are more in- formed than ever before. They are asking more questions and seeking to contribute to their care. Current health care pro- viders must respond intrepidly to this entreaty. In Texas, as well as many other states, today’s stan- dard of care includes a natural death act (ie, the Texas Natural Death Act). This act helps patients understand and complete advance directives before prob- lems arise.8

POINTS QF VIEW A recent informal survey I

conducted at the hospital in which I work found varied opin- ions about DNR orders among surgeons, anesthesia care providers, and perioperative nursing staff members. Some surgeons said that they believe any patient with a DNR whose condition necessitates a surgical procedure already may be at great risk of not surviving the procedure. They further said that because surgery and anesthesia are very traumatic to these indi- viduals, they have an obligation to try and return the patient to as close to his or her preoperative state as possible. A few sur-

geons said that a patient with a true DNR in place would not be brought to the OR; therefore, if a patient consents to surgery, he or she also will consent to a temporary suspension of the DNR. The surgeons agreed that during the preoperative consul- tation, it is imperative that the patient and his or her family members be informed, under- stand, and agree that the surgeon will attempt to restabilize any imbalances that occur during the surgical period.

Most anesthesia care providers that I surveyed agreed that patients have the right to partici- pate in the important decision of whether a DNR is suspended in the OR. All agreed that when preparing a patient with a DNR for a surgical procedure, commu- nication with the patient, as well as his or her family members, is a preoperative necessity.

Anesthesia itself changes a patient’s blood pressure, circula- tion, and level of consciousness, so some measures of stabilizing the patient are essential and indi- cated during a surgical proce- dure. These anesthesia care providers said that they attempt to reach a middle-of-the-road agreement with patients and family members regarding DNR and perioperative care. This includes the anesthesia care provider’s right to ventilate as needed and administer appropri- ate medications for hemodynam- ic stabilization during an intraop- erative event. According to the wishes of the patient and family members, however, many of these anesthesia care providers stop short of resuscitative efforts by not beginning cardiac com- pressions or defibrillation should cardiac arrest occur.

All the anesthesia care pro- viders surveyed agree that the care given to a patient with a DNR or other directive is in accordance with ethical guidelines approved by the American Society of anesthesiologist^.^ There are three possible scenarios for providing an outcome satisfactory to the patient. These include

a full attempt to resuscitate, a limited attempt with respect to the specific procedure per- formed (eg, chest compres- sions, defibrillation), and a limited resuscitative attempt in deference to the patient’s values or goals.’O

Each of these options involves informed communication among the patient, family members, and the anesthesia care provider.

Although perioperative nurses I surveyed said that patients have the right to choose and participate in their care, their opinion about DNR measures in the OR differed from those of anesthesia care providers and surgeons. Most of these perioperative nurses said that every attempt should be made to resuscitate all patients who code in the OR, regardless of whether a DNR order is in place.

These nurses also expressed a conviction that the OR is no place to die. They are of the opinion that, if at all possible, a patient about to die should be with family members and not strangers.

Perioperative nurses know that as a patient undergoes increasing- ly deeper levels of anesthesia, hearing is the last sense to go and the first to return, so they believe patients are entitled to hear family members talk and feel their touch at the time of death. These same nurses, who all come from differ- ent religious backgrounds, sup- port the philosophy that there is a

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spirit or soul in each of us that is seeking the comfort of home and family, especially at the time of death. Strong, seasoned, inde- pendent perioperative nurses, who easily can stand up to a sur- geon as a patient advocate, became teary-eyed when speak- ing about death in the OR. The normally cold room temperatures traditionally existing in today’s ORs pale in comparison to the emotional void experienced when perioperative nurses lose a patient.

BEING INFORMED The medical profession has a

responsibility to help patients ful- fill the concept of autonomy. For

patients to understand the disease process and options available, it is imperative that caregivers are hon- est and straightforward with them. It would be a liability for patients not to have the information need- ed to make important decisions concerning their health care.

could have tipped the scales of balance against a patient’s best decision-making abilities. When the patient is informed, he or she can choose an appropriate course of action, and, thus, accept more responsibility for the care given. This can lead to greater personal satisfaction.

In the health care arena, informed patients and family

The stress of an illness already

members can help choose the plan of care so they usually com- ply better and, thus, have a better chance of reaching the planned outcome. If a patient and his or her family members collaborate with the physician and anesthe- sia care provider, setting DNR parameters in the perioperative area can be accomplished in the best ethical interest of the patient. This also could afford the perioperative nurse better acceptance of a patient’s DNR status in the OR.

MARY R O B E R T S RN, BS, CNOR

BAYLOR UNIVERSITY MEDICAL CENTER IRVING, TEX

OR ASSISTANT NURSE MANAGER

NOTES 1. E L Bandman, B Bandman, Nursing Ethics

Through the Life Span, third ed (London: Prentice Hall International, 1995) 5.

Books, 1997).

ating room,” AORN Journal 57 (April 1993) 947-95 1.

the patient,” in Biomedical Ethics Opposing Viewpoints, ed D L Bender, B Leone (St Paul: Greenhaven, 1987)

2. D Nardo, The TriaE of Socrates (San Diego: Lucent

3. J M Reeder, “Do-not-resuscitate orders in the oper-

4. R S Jones, L LeShan, “Health care should focus on

189-193. 5. Bandman, Bandman, Nursing Ethics 7Imugh the

6. Ibid. Life Span, third ed.

7. J D Ramage, J C Bean, Writing Arguments: A Rhetoric with Readings (New York: Macmillan, 1992) 644.

8. “Death act: Directive to physicians,” Texas Medical Association (Practice Management), h t t p : / / w . texmed.orgipmt/lel/legalmetndaphy.asp#signers (accessed 3 July 2002.)

9. American Society of Anesthesiologists, “Ethical guidelines for the anesthesia care of patients with do-not- resuscitate orders or other directives that limit treatment,” in ASA Standard, Guidelines, and Statements (Park Ridge, Ill: American Society of Anesthesiologists, 200 1) 489.

10. Ibid.

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