Do not resuscitate orders in the perioperative period: patient perspectives.

The purpose of this study was to determine the perspectives and opinions of terminally ill patients regarding the management of their do not resuscitate (DNR) orders in the perioperative period. Eighteen patients who had DNR orders and were willing to discuss those orders and their intentions were identified by hospital nurses or hospice workers. An in-depth interview was conducted with each patient. Patients' intentions for DNR orders focused on themes of "being ready to die" and concern regarding financial and emotional cost to themselves and their families. Fifteen of 18 patients would agree to some type of surgery, some to palliative procedures, others to procedures unrelated to their primary disease. After a brief explanation of the different types of anesthesia and their risks, patients were asked how they would like their DNR orders to be respected during the perioperative period. Some would allow procedures in the operating room that ordinarily would be prohibited by a DNR order and felt that DNR orders should be suspended. Many felt that their DNR orders should be discussed with them preoperatively. Some wanted to be involved with decisions regarding specific procedures. Others were satisfied with discussing the intent of their orders. For various reasons and for various procedures, many patients with DNR orders are willing to undergo anesthesia and surgery. Anesthesiologists' awareness of the variety of opinions and perspectives held by patients regarding their DNR orders will enhance their preoperative discussion.

"Do not resuscitate" (DNR) orders in the perioperative period--a comparison of the perspectives of anesthesiologists, internists, and surgeons.

The purpose of this descriptive study is to compare and contrast the experience, perceptions, and opinions of practicing anesthesiologists, internists, and surgeons regarding "do not resuscitate" (DNR) orders in the perioperative period. A questionnaire was mailed to 600 internists and 600 surgeons. Responses from these two groups were analyzed and compared with the results of a previously reported survey of 420 anesthesiologists. One hundred ninety-two of 570 (34%) and 199/584 (34%) acknowledged responses were received from internists and surgeons, respectively. Anesthesiologists (114/190; 60%) were more likely than internists (61/182; 34%) or surgeons (71/194; 37%) to assume DNR suspension in the perioperative period and were less likely than their colleagues to discuss with the patient the implications of their DNR order during anesthesia and surgery. This assumption of DNR suspension by anesthesiologists was underestimated by both surgeons and internists. Anesthesiologists and surgeons were more similar than internists in their manner of utilization of resuscitative measures in the setting of a cardiopulmonary arrest. All groups were more likely to require DNR suspension for elective than for palliative cases. The majority of all groups concurred that physician responsibility for defining DNR status in the perioperative period should be shared by the anesthesiologist, surgeon, and primary care physician and not prescribed by hospital policy. The manner in which a DNR order is perceived in the perioperative period varies considerably among specialties and warrants further discussion among these groups.

"Do not resuscitate" (DNR) orders and the anesthesiologist: a survey.

Anesthesiologists were surveyed to determine their experience and opinions regarding "Do Not Resuscitate" (DNR) orders in the perioperative period. Four hundred fifteen questionnaires were mailed and 193 (47%) were returned. One hundred sixty-one (87%) of 186 respondents had been requested to provide (and more than two-thirds had provided) monitored anesthesia care, regional anesthesia, or general anesthesia to a patient with a DNR order. Almost two-thirds of the respondents assume DNR suspension in the perioperative period and only half discuss this assumption with the patient/guardian. Less than 50% of respondents would require DNR suspension for a palliative procedure contrasted with > 60% for an elective procedure. After agreeing to a patient's decision to retain their DNR status, > 67%, > 58%, < 49%, and < 33% would utilize positive pressure ventilation with a mask, vasoactive drugs, endotracheal intubation, or defibrillation, respectively, in the event of a cardiopulmonary arrest in the perioperative period. These findings suggest much ambiguity regarding DNR orders in the perioperative period. Further discussion among physicians and patients is warranted.