Key result
The authors reiterate the need for UK guidelines on managing pre-existing DNAR orders during surgery and anaesthesia, suggesting documented discussions with patients regarding peri-operative resuscitation.
Pre-existing DNAR orders require specific reconsideration and discussion prior to surgery and anaesthesia, highlighting the need for formal UK guidelines.
We thank Dr Coldicott for her interest in our editorial. As stated in the editorial, ‘Do Not Attempt Resuscitation’ (DNAR) orders are instituted on the assumption that cardiopulmonary arrest will be a spontaneous event that is the culmination of the dying process in a patient who has a terminal illness or a poor quality of life. The editorial sought to highlight the difficulties that may arise when patients with pre-existing DNAR orders are scheduled for surgery and anaesthesia and this assumption no longer applies. Confusion about what is best medical practice in this situation is then almost inevitable, which resulted in our request for UK guidelines similar to those published by the American Society of Anesthesiologists in 1993 [1]. The resuscitative measures that may be needed during anaesthesia and surgery as a result of iatrogenic cardiopulmonary depression then require reconsideration as they will be needed in circumstances not considered when the DNAR order was originally put in place. Although Dr Coldicott states that advance directives will become legally binding as part of the Mental Capacity Act, they will not be legally binding unless the circumstances which subsequently arise have been considered when the advance directive was originally made [2]. Since it is unlikely that surgery and anaesthesia will have been contemplated, but yet, as discussed, may be appropriate, the existing DNAR order will probably no longer be valid in the peri-operative period. We are not suggesting that patients are resuscitated against their wishes. We are trying to help anaesthetists in the UK facing this situation and advising them what course of action to follow. We suggest that the full range of resuscitative measures at the anaesthetist's disposal, including cardiopulmonary resuscitation, are discussed with the patient, or other individuals if the patient lacks competence, and a documented decision taken as to what is deemed appropriate in the circumstances. This may differ in a small or large way from what has been stated in a pre-existing advance directive. Guidelines to this effect from the Association of Anaesthetists of Great Britain and Ireland would be welcomed.
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McBrien et al. (2006) conducted a letter in Patients with pre-existing DNAR orders scheduled for surgery and anaesthesia. The authors reiterate the need for UK guidelines on managing pre-existing DNAR orders during surgery and anaesthesia, suggesting documented discussions with patients regarding peri-operative resuscitation.
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