Do Not Attempt Resuscitation decisions in the peri‐operative period

The authors of the Association’s Working Party report ‘Do Not Attempt Resuscitation (DNAR) Decisions in the Peri-operative Period’ [1] should be congratulated on producing guidance emphasising early decision-making, involvement of patients, their carers and family, and the need for accurate documentation and communication. Furthermore, highlighting the fact that survival rates following cardiopulmonary arrest in the operating theatre are greater than in general hospital wards is essential [2, 3], as this might alter a competent patient’s decision to accept cardiopulmonary resuscitation in the peri-operative period. We are, however, puzzled by the proposal of three options for dealing with an existing DNAR decision when the patient requires anaesthesia. Clearly, options 1 (surgery and anaesthesia are to proceed with cardiopulmonary resuscitation to be used if arrest occurs) and 3 (no changes to be made to the DNAR decision) are essential, but option 2 seems only to serve to confuse a simple situation. The term DNAR is intended to provide unambiguous instruction on one specific point: that a person should not undergo cardiopulmonary resuscitation in the event of cardiorespiratory arrest. Prior to and during anaesthesia, it is only necessary to know if the patient in question has an active DNAR decision. There is no need to seek to modify the decision to ‘…permit the use of drugs and techniques commensurate with the provision of anaesthesia…’, e.g. vital signs monitoring, airway manipulation, intubation, ventilation and the use of vasoactive drugs, as the decision only becomes relevant if cardiopulmonary arrest occurs. Choosing to use these essential anaesthetic techniques, which happen also to be components of cardiopulmonary resuscitation, does not impact on a patient’s DNAR decision unless the patient suffers a cardiopulmonary arrest. At such a time, either option 1 or 3 would become active. Furthermore, we disagree that option 3 is incompatible with the provision of general anaesthesia for any type of surgical intervention, under most circumstances. Where a fully informed, competent patient makes a considered decision that they do not wish to receive cardiopulmonary resuscitation and accepts that such refusal carries serious consequences if cardiopulmonary resuscitation is required, but is keen to undergo surgery, we can see no reason why general anaesthesia and surgery should be denied. In such circumstances, it would be entirely appropriate for an anaesthetist to use all necessary measures to maintain cardiopulmonary stability and prevent cardiopulmonary arrest during anaesthesia but, on the basis of patient request, to withhold cardiopulmonary resuscitation if it became necessary. We can see no reason why such actions would be construed as an act of euthanasia or assisted suicide. Professor Smith contributed to the 2007 BMA, RC (UK) and RCN joint statement and to the development of the RC (UK) model DNAR form (http://www.resus.org.uk).