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• W4245360971 abstract "AORN JournalVolume 112, Issue 4 p. 392-395 From AORNFree Access AORN Position Statement on Perioperative Care of Patients With Do-Not-Resuscitate or Allow-Natural-Death Orders First published: 29 September 2020 https://doi.org/10.1002/aorn.13183AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat POSITION STATEMENT AORN believes: reconsideration of do-not-resuscitate or allow-natural-death orders is required and is an integral component of the care of patients undergoing surgery or other invasive procedures;1-5 health care providers should have a discussion with the patient or patient's surrogate about the risks, benefits, implications, and potential outcomes of anesthesia and surgery in relation to the do-not-resuscitate or allow-natural-death orders before initiating anesthesia, surgery, or other invasive procedures;2, 3, 5-7 clear identification methods (eg, standardized wristbands) for the patient who has a do-not-resuscitate or allow-natural-death order may decrease the risk for miscommunication;6, 8 and use of acronyms and abbreviations (eg, DNR, DNAR, AND) should be discouraged to decrease the risk of miscommunication.1, 9, 10 AORN believes the following strategies should be followed during reconsideration of do-not-resuscitate or allow-natural-death decisions: Communication With the Patient and Patient's Family Members The patient's physicians and anesthesia care providers are responsible for discussing and documenting issues with the patient and/or family members to determine whether the do-not-resuscitate or allow-natural-death orders are maintained or completely or partially suspended during anesthesia and surgery.2, 3, 6, 7, 11 The discussion should include goals of the surgical treatment, potential for resuscitative measures and a description of what these measures include (eg, whether withholding resuscitation compromises the patient's basic objectives for surgery), and potential outcomes with and without resuscitation.2, 3, 6, 12 Communication With the Health Care Team Preoperatively, the health care team and the patient or surrogate should communicate about do-not-resuscitate or allow-natural-death decisions. In accordance with patient privacy and confidentiality, the health care organization should develop a standard method of communication that informs all direct care providers of the patient's decisions, which may include standardized wristbands to indicate do-not-resuscitate or allow-natural-death status. Throughout the process, the patient has the right to modify any decision. Changes should be communicated to all direct care providers.6, 13 Patient situations that may require further ethical deliberation before surgical intervention may benefit from consultation with the hospital's ethics advisory committee. Appropriate information should be provided to the perioperative team in order to support the patient's or surrogate's health care decisions.2, 4, 6 Documentation The preoperative reconsideration discussion of do-not-resuscitate or allow-natural-death decisions should be clearly documented and reported in the hand-over communication to direct perioperative care providers. If the patient has chosen to suspend or modify the do-not-resuscitate or allow-natural-death order during the intraoperative period, a specific time frame should be defined for reinstating the pre-existing do-not-resuscitate or allow-natural-death order in accordance with the patient's or surrogate's decisions. Staff Assignments If the perioperative registered nurse has a moral objection to the patient's decision, he or she should be allowed to make a reasonable effort to find another perioperative registered nurse to provide care to the patient. If another perioperative registered nurse is not available, the patient's decision will be upheld, recognizing that there are times when a patient's decisions take precedence in a clinical situation.5, 6 If the perioperative registered nurse identifies another team member's moral objections to the patient's decision, he or she should assist with facilitating reassignment of the individual. RATIONALE Patient autonomy must be respected and is the professional responsibility of the health care team. The perioperative registered nurse, as a patient advocate, has an ethical and moral responsibility to uphold the rights of patients.6, 11, 14, 15 It has been reported that approximately 15% of patients who have do-not-resuscitate or allow-natural-death orders undergo surgical procedures and anesthesia management.16 These procedures often are for palliative care, to relieve pain or distress, to facilitate care, or to improve the patient's quality of life. Do-not-resuscitate or allow-natural-death orders should not mean that all treatment is stopped and the need for medical and nursing care is eliminated, but rather that the patient has made certain choices about end-of-life decisions.1, 6 A patient's rights do not stop at the entrance to the operating or procedure room. Automatically suspending a do-not-resuscitate or allow-natural-death order during surgery undermines a patient's right to self-determination.12 Professional organizations support developing policies to address do-not-resuscitate or allow-natural-death orders in the operating or procedure room.2, 6, 12, 17-19 Glossary Allow natural death: A specific directive, written by a physician, to promote discussions with the patient and his or her family members about end-of-life decisions (eg, intubation, mechanical ventilation, IV fluids, medications, types of nutrition, comfort measures) in proactive terminology (eg, guiding caregivers and families in the direction of what action to take as opposed to what action not to take), thus shifting the focus and providing clarity about the intent of the care that will be provided to the patient. Do-not-resuscitate order: A specific directive, written by a physician, mandating that cardiopulmonary resuscitation should not be performed. Do-not-resuscitate decision: The patient's or surrogate's directive regarding end-of-life choices. Required reconsideration: An event that allows a patient or surrogate to participate in decisions about the use of procedures and interventions (eg, cardiopulmonary resuscitation, intubation, medication administration) that the patient or surrogate would permit during the perioperative phase and that offers caregivers an opportunity to explain the significance of cardiac arrest and resuscitation in the perioperative setting. REFERENCES 1Venneman SS, Narnor-Harris P, Perish M, Hamilton M. “Allow natural death” versus “do not resuscitate”: Three words that can change a life. J Med Ethics. 2008; 34(1): 2- 6. 2 American Academy of Pediatrics. Interpretation of do not resuscitate orders for children requiring anesthesia and surgery. Pediatrics. 2018; 141(5):e20180598. https://doi.org/10.1542/peds.2018-0598. 3Bernat JL. Ethical issues in the perioperative management of neurologic patients. Neurol Clin. 2004; 22(2): 457- 471. 4Ewanchuk M, Brindley PG. Perioperative do-not-resuscitate orders—doing “nothing” when “something” can be done. Crit Care. 2006; 10(4): 219. 5Morrison W, Berkowitz I. Do not attempt resuscitation orders in pediatrics. Pediatr Clin North Am. 2007; 54(5): 757- 771. 6Ball KA. Do-not-resuscitate orders in surgery: decreasing the confusion. AORN J. 2009; 89(1): 140- 146. 7Scott TH, Gavrin JR. Palliative surgery in the do-not-resuscitate patient: ethics and practical suggestions for management. Anesthesiol Clin. 2012; 30(1): 1- 12. 8Sehgal NL, Wachter RM. Identification of inpatient DNR status: a safety hazard begging for standardization. J Hosp Med. 2007; 2(6): 366- 371. 9Truog RD, Waisel DB, Burns JP. Do-not-resuscitate orders in the surgical setting. Lancet. 2005; 365(9461): 733- 735. 10Murphy P, Price D. How to avoid DNR miscommunications. Nurs Manage. 2007; 38(3): 17, 20. 11Schlairet MC, Cohen RW. Allow-natural-death (AND) orders: legal, ethical, and practical considerations. HEC Forum. 2013; 25(2): 161- 171. 12 American Society of Anesthesiologists. Ethical Guidelines for the Anesthesia Care of Patients With Do-Not-Resuscitate Orders or Other Directives That Limit Treatment. https://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/ethical-guidelines-for-the-anesthesia-care-of-patients.pdf. Reaffirmed October 17, 2018. Accessed January 7, 2020. 13Guarisco KK. Managing do-not-resuscitate orders in the perianesthesia period. J Perianesth Nurs. 2004; 19(5): 300- 307. 14 AORN Perioperative Explications for the ANA Code of Ethics for Nurses With Interpretive Statements. https://www.aorn.org/guidelines/clinical-resources/code-of-ethics. Accessed January 7, 2020. 15 Standards of Perioperative Nursing. https://www.aorn.org/guidelines/clinical-resources/aorn-standards. Accessed January 7, 2020. 16 ECRI Institute. Do-not-resuscitate orders. Healthcare Risk Control. 2008; 2(Ethics 3): 1- 13. 17 American College of Surgeons. Statement on advance directives by patients: “do not resuscitate” in the operating room. Bull Am Coll Surg. 2014; 99(1): 42- 43. 18 American Association of Nurse Anesthetists. Considerations for development of an anesthesia department policy on do-not-resuscitate orders. https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/reconsideration-of-advanced-directives.pdf?sfvrsn=550049b1_6. Published November 2015. Accessed January 7, 2020. 19 American Nurses Association. Position Statement on Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/nursing-care-and-do-not-resuscitate-dnr-and-allow-natural-death-and-decisions/. Revised March 12, 2012. Accessed January 7, 2020. Resources 20Shapiro ME, Singer EA. Perioperative advance directives: do not resuscitate in the operating room. Surg Clin North Am. 2019; 99(5): 859- 865. 21 US Department of Health and Human Services, Centers for Medicare & Medicaid Services. Contracts. 42 CFR §434 2019. https://www.ecfr.gov/cgi-bin/text-idx?SID=b245cb997a748379f0c9d820ea4b4a23&mc=true&node=pt42.4.434&rgn=div5. Revised October 1, 2019. Accessed January 7, 2020. 22 US Department of Health and Human Services, Centers for Medicare & Medicaid Services. Grants to States for Medical Assistance Programs. 42 CFR §430 2019. https://www.ecfr.gov/cgi-bin/text-idx?SID=b245cb997a748379f0c9d820ea4b4a23&mc=true&node=pt42.4.430&rgn=div5. Revised October 1, 2019. Accessed January 7, 2020. 23 US Department of Health and Human Services, Centers for Medicare & Medicaid Services. Home Health Services. 42 CFR §484 2019. https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=678413c0e8cb09eb36b0dc0ba79f3ed2&mc=true&r=PART&n=pt42.5.484. Revised October 1, 2019. Accessed January 7, 2020. 24 US Department of Health and Human Services, Centers for Medicare & Medicaid Services. Provider Agreements and Supplier Approval. 42 CFR 489 2019. https://www.ecfr.gov/cgi-bin/text-idx?SID=678413c0e8cb09eb36b0dc0ba79f3ed2&mc=true&node=pt42.5.489&rgn=div5. Revised October 1, 2019. Accessed January 7, 2020. 25 US Department of Health and Human Services, Centers for Medicare & Medicaid Services. Requirements for States and Long Term Care Facilities. 42 CFR §483 2019. https://www.ecfr.gov/cgi-bin/text-idx?SID=678413c0e8cb09eb36b0dc0ba79f3ed2&mc=true&node=pt42.5.483&rgn=div5. Revised October 1, 2019. Accessed January 7, 2020. 26 US Department of Health and Human Services, Centers for Medicare & Medicaid Services. State Organization and General Administration. 42 CFR §431 2019. https://www.ecfr.gov/cgi-bin/text-idx?SID=678413c0e8cb09eb36b0dc0ba79f3ed2&mc=true&node=pt42.4.431&rgn=div5. Revised October 1, 2019. Accessed January 7, 2020. Publication History Original approved by the House of Delegates, Atlanta, Georgia, March 1995 Reaffirmed by the Board of Directors: October 1999 Reaffirmed by the Board of Directors: December 2004 Revision approved by House of Delegates: March 2009 Reaffirmed by the Board of Directors: February 2020 Sunset review: February 2025 Volume112, Issue4October 2020Pages 392-395 ReferencesRelatedInformation" @default.
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