Resuscitation and DNR: ethical aspects for anaesthetists

Abstract

Autonomy is a central ethical principle of medical practice. The physician's autonomy is usually expressed in concert with the other, overriding, ethic of medical care: beneficence. The au tonomy of patients, however, has had a growing influence on medical decision-making and can complicate the process. One area where this is especially true is the manner in which cardiopulmonary resuscitation is disallowed: the do-not-resuscitate (DNR) order. Cardiopulmonary resuscitation initially was a therapy automatically instituted in emergencies because it was life-saving. Data began to show, however, that this drastic meas ure was not always effective. Therefore, its use began to be limited through DNR orders, and policies about DNR orders have been developed to ensure it, in turn, is instituted properly. Besides being used when CPR is futile, the DNR order also serves as a formal means of accounting for a patient's auton omy. Data show, however, that patients are not routinely con sulted on this issue even though they want to discuss it. In these cases, quality of life, a patient's subjective evaluation, serves as the basis of a DNR order and makes mandatory communication between physician and patient. Such commu nication, however, can be obstructed by social values about life and death and the urgent nature of medical care in these sit uations. To show how such communication ought to be in corporated into medical decision-making, one of the most difficult situations is examined hypothetically: the patient who has a DNR order but who consents to undergo anaesthesia and surgery. In these cases, frequent communication between physician and patient about each therapy and its effect most often will resolve dilemmas. © 1995 Canadian Anesthesiologists.