Do not attempt resuscitation decisions in the perioperative period

Abstract

Editor—Many of the opinions expressed by Knipe and Hardman in their recent editorial1Knipe M Hardman JG Past, present, and future of ‘Do not attempt resuscitation’ orders in the perioperative period.Br J Anaesth. 2013; 111: 861-863Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar have previously been published as correspondence by Poplett and Smith with a comprehensive reply from ourselves2Poplett N Smith GB McBrien ME Heyburn G Do Not Attempt Resusciation decisions in the peri-operative period.Anaesthesia. 2010; 65: 82-83Crossref PubMed Scopus (3) Google Scholar after publication of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines on ‘Do Not Attempt Resuscitation (DNAR) Decisions in the Perioperative Period’3Association of Anaesthetists of Great Britain and IrelandDo Not Attempt Resuscitation (DNAR) Decisions in the Perioperative Period. 2009Google Scholar in 2009 to which we contributed. The correspondence2Poplett N Smith GB McBrien ME Heyburn G Do Not Attempt Resusciation decisions in the peri-operative period.Anaesthesia. 2010; 65: 82-83Crossref PubMed Scopus (3) Google Scholar should be read in conjunction with this reply. The purpose of publishing the guidelines was to: (i)Ensure patients approaching the end of their life receive high-quality treatment until they die with dignity, in accordance with General Medical Council guidance which has subsequently been published.4General Medical CouncilTreatment and Care Towards the End of Life: Good Practice in Decision Making. 2010Google Scholar The editorial does not reference this practice defining document.(ii)Protect healthcare professionals from retrospective accusations of assault arising from resuscitative interventions for which consent had not been granted, and from assisting euthanasia by pharmacologically inducing cardiopulmonary instability and then actively withholding cardiopulmonary resuscitation (CPR).Definitions are so essential to this subject that a separate section of the AAGBI guidelines was dedicated to them. The definition of CPR in the guidelines was taken from the Joint Statement from the British Medical Association, The Resuscitation Council (UK), and the Royal College of Nursing 2007,5British Medical Association, Resuscitation Council (UK) and Royal College of NursingDecisions Relating to Cardiopulmonary Resuscitation. A joint statement. 2007Google Scholar which stated: ‘CPR is undertaken in an attempt to restore breathing and spontaneous circulation in a patient in cardiac and/or respiratory arrest. CPR … usually includes chest compressions, attempted defibrillation with electric shocks, injection of drugs and ventilation of the lungs’. The much narrower definition of CPR given by Knipe and Hardman is not referenced. In our opinion, the ‘improvements’ suggested by the authors make the two purposes stated above for publishing the AAGBI guidelines less likely. The authors’ plea for simplification and greater patient autonomy cannot be fulfilled by arguing that a DNAR decision implies refusal of the elements of CPR only after cardiac arrest has taken place. If that was the case, it would hypothetically be defensible to intubate and ventilate the lungs of a DNAR patient in respiratory failure at ward level before cardiorespiratory arrest, which is clearly what the patient has refused by implementation of their DNAR decision. Autonomy is only achieved by full participation by individuals in making informed choices about their healthcare. The Lay Representative on the AAGBI working party had input to all discussions during the process and was in concordance with the final position reached by the other members including legal representatives and others with ethical expertise. The guidelines sought to offer options, using accurate definitions and explicit legal and ethical reasoning, to patients and healthcare professionals rather than simplified processes requiring subjective interpretation of concepts as suggested by Knipe and Hardman. The final point we wish to refute is the suggestion by Knipe and Hardman that by implementing the AAGBI guidelines ‘Patients are given the choice of either altering their DNAR order or not undergoing the … operation’.1Knipe M Hardman JG Past, present, and future of ‘Do not attempt resuscitation’ orders in the perioperative period.Br J Anaesth. 2013; 111: 861-863Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar The three option approach along with the DNAR management consent form in Appendix 1 of the AAGBI guidelines clearly lets the patient, proxy decision maker, or doctor in charge of the patient’s care along with relatives and carers, if indicated, decide what resuscitative measures, if any, will be embarked upon and outlines a process for conflict resolution. There is no suggestion of coercion anywhere in the document, and we are disappointed that the authors are of the opinion that the AAGBI guidelines will ‘act to encourage patients towards a course of action that they would not choose freely’. This accusation is unjustified. Those involved in producing the guidelines had motives which were patient centred at all times. Both M.E.M. and G.H. were members of the AAGBI Working Party producing the Do Not Attempt Resuscitation (DNAR) Decisions in the Perioperative Period guidelines in 2009.