DNR: Negotiating and respecting patient goals in surgery

He’s 15, Needs This Operation and He’s DNR!
Monday, 9:50-10:50 a.m.
Upper Level 20B-C


David Mann, M.D.

Advance directives are not always helpful. Take the patient who needs a palliative surgery but has a do-not-resuscitate (DNR) order. Safely administering anesthesia is difficult enough without a DNR order in place. If the patient is 15, old enough to voice considered opinions about resuscitation but not old enough to give legal consent, the physician anesthesiologist can be in a difficult position.

“From a practical perspective, conducting surgery and administering anesthesia under a DNR can by touchy,” said David Mann, M.D., Associate Professor of Anesthesia and Pediatrics at the Baylor College of Medicine, Houston. “There is a misconception that if someone with a DNR order comes into the O.R., the DNR is automatically waived by their consent to the surgery. The reality is that a patient can be DNR in the O.R., but their risk of dying rises dramatically. Drugs that anesthesiologists use every day to manipulate heart rate and blood pressure during anesthesia would be considered resuscitative drugs anywhere else in the hospital. Patients, but also many physicians and surgeons, often don’t recognize or understand that difference.”

Dr. Mann will discuss the practical and ethical implications of advance directives during a Professional Issues session, “He’s 15, Needs This Operation and He’s DNR!” from 9:50 to 10:50 a.m. Monday in Upper Level 20 B-C. Procedures and medications that appear to be resuscitative to the patient are standard practice in anesthesiology. Standard rescue procedures, chest compressions or cardioversion may contravene a DNR.

Anesthesiologists need to discuss, educate and even negotiate interventions that further the patient’s wishes and help achieve his or her goals. The discussion becomes even more complex when the patient is a minor.

Most patients under the age of 18 cannot provide informed consent because they are legal minors, Dr. Mann said. That’s seldom an issue for very young patients. But as patients move into their middle-teen years, they are becoming mature enough to have their own ideas, wishes and goals, including those related to living and dying.

“A normal 15-year old is as big as I am,” Dr. Mann said. “My choice is to get him to accept, with his parent’s consent, what I’ll be doing to keep him safe during anesthesia. You need informed consent from the legal guardian (parents) when your patient is a minor; and you need informed assent from the patient if he or she is old enough to understand what could happen.”

Informed consent versus informed assent is a quirk of pediatrics, Dr. Mann was quick to note. But the ethical issues that can come with advance directives are universal.

“Adults have DNR orders, too, and when that DNR prevents you from acting, it can be devastating to all of the providers,” he said. “A DNR that prevents you from cardioverting a patient on the table doesn’t just affect the anesthesiologist and the surgeon, it affects the nurses, the scrub techs and the medical students who happen to be on rotation. You need that discussion with the patient and the family about what they are consenting to, what they are refusing to consent to and the potential consequences for each of those choices.”


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