Anaesthetists Receive New Guidance To Help Resolve Dilemmas Posed By Do Not Attempt Resuscitation Orders

Main Category: Pain / Anesthetics
Article Date: 05 Jun 2009 - 6:00 PDT

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The body that represents anaesthetists in the UK and the Republic of Ireland has issued new guidelines to help their members through the ethical and clinical maze of how to treat terminally ill patients with Do Not Attempt Resuscitation (DNAR) orders when they need an operation. "DNAR orders tell medical staff what the patient's wishes are in an emergency" explains Dr Leslie Gemmell, Honorary Secretary of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and Chair of the working party that put together the new guidelines.

"For example they may say that the patient does not want to be resuscitated if their heart stops or be put on a ventilator if they are unable to breath unaided.

"The problem is that DNAR orders pose a real conundrum when patients are scheduled to undergo surgery, because many techniques routinely undertaken in the course of anaesthesia would ordinarily be classed as resuscitation.

"These can include helping colleagues to carry out procedures to alleviate distress, provide pain relief or enhance the patient's quality of life. For example we may need to insert support devices, such as feeding tubes, or provide anaesthesia for an unrelated emergency operation, such as an acute appendicitis, or a chronic but not life-threatening routine procedure, such as removing a painful bowel obstruction.

"It is increasingly common for patients to be scheduled for anaesthesia and surgery despite the fact that the patient has signed a DNAR order."

Guidelines have been available in the USA since 1993 and Canada since 2002. In the UK, a framework to support decisions relating to cardiac resuscitation was jointly published by the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing in 2007. "These recommend that DNAR decisions should be reviewed before surgery and anaesthesia, but detailed guidance on how that decision should be managed is not provided" explains Dr Gemmell, a consultant anaesthetist from Wales.

"Although it is has been a common presumption that DNAR decisions should be fully withdrawn in the period leading up to an operation, we recognise that this may not be in the patient's best interests. "This prompted us to carry out a review of the basic legal and ethical principles involved so that we could advise anaesthetists and anaesthetic departments how to manage the challenging ethical and clinical dilemmas that may arise."

The AAGBI's guidelines - Do Not Attempt Resuscitation (DNAR) Decisions in the Perioperative Period - are intended for all clinicians and healthcare workers involved with adult patients during the perioperative period. These guidelines should be used in conjunction with the 2007 joint statement - which highlights the human dignity and transparent decision making promoted by the Human Rights Act 1998 - and any existing legislation.

In England and Wales the legal framework for DNAR decisions is provided by the Mental Capacity Act 2005 and in Scotland the Adults with Incapacity (Scotland) Act 2000 provides a similar protective framework. Northern Ireland has no formal legislation covering adults who lack competency and relies on the common law position that has been developed in this area. The Republic of Ireland has no specific legislation covering advance decisions like DNAR orders, but the Irish Council for Biothethics published their finding of a review of the ethical and legal issues surrounding advance directives in 2007. The AAGBI feels that national guidance is needed to provide legal clarity in the Republic.

The AAGBI guidance makes 12 key recommendations, which can be summarised as follows:

-Managing DNAR decisions in the perioperative period should focus on what resuscitative measures will be embarked on rather than what will not be done.

-Patients with DNAR orders should be referred to the anaesthetic and surgical teams as early as possible.

-Any DNAR decision should be reviewed by clinicians and patients, or their representatives, before surgery and anaesthesia.

-A decision should be made to either discontinue, modify or make no changes to the DNAR order during surgery or anaesthesia, bearing in mind that the third option is likely to preclude surgery in many cases.

-The agreed DNAR management option should be recorded in the patient's notes.

-It should also be communicated to all healthcare staff managing the patient in the operating theatre and recovery areas.

-The legal hierarchy on who should make a DNAR decision - the patient, their representative or the senior clinician - should be respected.

-If the various parties cannot agree, the person with the legal right or responsibility to make the decision should have the final word.

-If the clinician cannot agree with the outcome of a DNAR decision they should hand the case over to a suitably qualified colleague in line with the General Medical Council's guidelines.

-Legal advice should be sought immediately if it is unclear who has the right or responsibility to make the DNAR decision.

-In an emergency, doctors must do what is in the best interest of the patient using the information available.

-The DNAR management option should normally apply in the operating theatre and recovery area, with the DNAR decision reinstated when the patient returns to the ward.
The full guidelines have been posted on the AAGBI's website http://www.aagbi.org and an interview with Dr Leslie Gemmell can be viewed on YouTube at http://www.youtube.com/watch?v=3_bimcl4Fgw

Notes

- Document reference: Do Not Attempt Resuscitation Orders (DNAR) Decisions in the Perioperative Period. Association of Anaesthetists of Great Britain and Ireland. (Launched June 2009). http://www.aagbi.org

- 2007 joint statement reference: Resuscitation Council. Decisions Relating to Cardiopulmonary Resuscitation. A Joint Statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. (2007). http://www.resus.org.uk/pages/DNAR.htm

- The Association of Anaesthetists of Great Britain and Ireland is a leading representative body for anaesthetists in the UK and overseas and is one of the UK's largest single grant providers for anaesthetic research. It currently has around 10,000 members. http://www.aagbi.org

- Anaesthetists are specialist doctors involved in the care of two-thirds of all hospital patients. Their expertise extends beyond the main operating theatre to acute and chronic pain management, leading resuscitation teams, managing Intensive Care Units, working in maternity units, accident and emergency departments and radiology, the care of some dental patients and the transfer of critically ill patients.

Source
Association of Anaesthetists of Great Britain and Ireland