SURGICAL ETHICS CHALLENGESJames W. Jones, MD, PhD, MHA, Section Editor

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Defining, aligning, or declining do not resuscitateduring surgeryJames W. Jones, MD, PhD, MHA, and Laurence B. McCullough, PhD, Houston, Tex

A Professor A. Droit, 93 years of age, formerly your college ethics teacher, developed a painful ischemic foot from distalaortic blockage. A daughter, who is a nurse, brought him to the hospital. He has multiple comorbidities, includingleukemia for which he is getting chemotherapy. He agrees to surgery but hands you a completed do not resuscitate (DNR)form and insists it be honored throughout his care. As the operative wound is being closed, he has a slow ventriculartachycardia, which does not respond to intravenous therapy. You should:

A. Do nothing else without permission from the daughter.B. Defibrillate once and inform him later if he survives.C. Defibrillate once and do not inform him.D. Institute a full resuscitation and do not inform him.E. Automatically suspend the DNR when in the operating room.

Must not all things at last be swallowed up in death?

eSocrates (in Plato’s Phaedo)

Death, so far as we know, is the final parameter. Med-ical knowledge stops when death arrives. Surgeons, inparticular, spend their entire careers jousting with Death.Even when everything possible has been done, it is along painful trip to the waiting room delivering to the pa-tient’s loved ones some of the worst news of their lives. Theattending surgeon often considers it a blotch on the oper-ative record and a matter to explain at the next mortalityconference.

Because of the fear that death’s ubiquity and finalitygenerates, many of ethics’ knottiest challenges are associ-ated with end-of-life issues.1 In the distant past, it was anAdmiral David Farragut’s “Damn the torpedoes, full speedahead” routine. But more tools have become available toforestall the reaper, often at a great disease-related andiatrogenic burden for minimal clinical return.

For most of the history of Western medicine, the stan-dard of care was for physicians not to take on desperate

The Center for Medical Ethics and Health Policy, Baylor College ofedicine.or conflict of interest: none.rint requests: James W. Jones, MD, PhD, MHA, 31 La Costa Dr,ontgomery, TX 77356 (e-mail: jwjones@bcm.tmc.edu).editors and reviewers of this article have no relevant financial relationshipsdisclose per the JVS policy that requires reviewers to decline review of anyanuscript for which they may have a conflict of interest.sc Surg 2014;59:1152-3-5214/$36.00yright � 2014 by the Society for Vascular Surgery.://dx.doi.org/10.1016/j.jvs.2014.02.019

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cases in which the physician could reliably predict a highrisk of death. The correlate of this standard of care wasthat physicians should stop treating patients who becameso desperately ill that they were likely to die. This standardwas articulated in the Hippocratic texts and brought toconsiderable sophistication in the early 18th century byFriedrich Hoffmann (1660-1742) in his Medicus Politicusor the “politic physician.” The politic physician understoodthat he was subordinate to the power of the well-to-dowho could afford his fees and therefore should conducthimself with prudence: Identify his legitimate self-interestand act to protect it.

The logic of prudence in the care of the desperately illwas straightforward. It would injure one’s reputation tobecome known as a physician or surgeon whose patientsdied in high numbers, and loss of reputation meant lossof patients and loss of income.2 There being none of theeconomic security that we now take for granted but shouldnot (the historically unprecedented economic security ofsurgeons in the United States dates only from after WorldWar II), a high mortality rate could result in poverty.

Noting the onset of death was simple, for eons whenthe signs of life were absentddeath was perpetual. Thena half-century ago, a retired professor of engineering, a sur-gical resident, and an engineering student combinedexternal electrical shock, mouth-to-nose ventilation, andclosed chest compressions to jump-start life. This geniusteam used their method, which they named cardiopulmo-nary resuscitation (CPR), on 20 patients, resuscitating14. CPR complicated the determination of end-of-lifeand has provided bioethicists with perhaps their most pop-ular topic.3

JOURNAL OF VASCULAR SURGERYVolume 59, Number 4 Jones and McCullough 1153

At first, the patient population was carefully chosen ac-cording to whether resuscitation would be used. But asCPR teams were formed, they became more experiencedand would race to save patients of whom they had noknowledge. Many were brought back to resume dying.DNR orders became the solution to avoid predicaments.Indeed, resuscitation has become a default intervention.Orders must be written not to do it, unlike every otherorder a surgeon writes.

American medicine is in transition with the ethics ofend-of-life issues from an aging population, increasingcost of medical technology, and futility issues. Providingunnecessary care is ethically just as wrong as failing to pro-vide indicated care competently.4 The definition of futilityenables physicians to more accurately determine and feeljustified in stopping pointless care. DNR orders recognizeand are grounded in the futility concept.

There is an important preventive ethics lesson fromthis case. Code status involves important details thatneed clarification. Although 57% of patients agree thatDNR orders should be suspended in the operating room,the overwhelming majority state the surgeon shoulddiscuss details with the patient.5 Professor Droit shouldhave been asked to specify what elements of a resuscitationwere allowable and for how long. Dispassionate clinicalevaluation of the patient’s preferences should then haveensued.

Uninformed of the patient’s wishes, the surgeon mightdecide that a DNR order does not apply to a partial resus-citation, only a full resuscitation. This reasoning is morallysuspect, for without understanding of the patient’s degreeof knowledge of the resuscitation’s components andpermission to use each, the patient’s autonomy is not beingfully respected.6 Options B and C are tempting because asingle shock would likely reverse the predictably fataloutcome, but a DNR order means quite literally no resus-citation efforts by medical personnel. Injection of an antiar-rhythmic drug is primarily therapeutic, whereas applyingthe defibrillator is clearly a resuscitative measure. OptionB and C are unacceptable. Option C, by not informingthe patient of a major intraoperative event, is ethicallyworse. Option D is the ethical equivalent of option Cand thus is incorrect.

Anesthesiologists and surgeons quite reasonably havetaken the view that intraoperative arrest of a seriously orterminally ill patient should be regarded as a correctableside effect of anesthesia and not a function of thepatient’s underlying disease or injury.1 Moreover, intra-operative resuscitation maintains homeostasis, and pa-tients usually recover, in sharp contrast to the overall

low success rate of resuscitation (15%) elsewhere in thehospital.

Seriously or terminally ill patients who consent to sur-gery can reasonably be presumed to want its functionalimprovements and palliative effects, but they will not expe-rience these outcomes if an intervention that is usuallyeffective in helping to achieve them is withheld. A strongcase can be made on both clinical grounds and on the basisof a reasonable assumption about patients’ preferences thatDNR orders should be suspended during surgery for seri-ously ill or terminally ill patients.

These arguments for suspension of DNR orders inthe operating room do not allow the patient’s autonomyto be routinely disregarded. These arguments do supportproviding the rationale for suspending the patient’s DNRorder and recommending that he accept this managementplan. Providing this information was essential for empower-ing the exercise of the patient’s autonomy in the informedconsent and therefore should have occurred. If the patienthad refused to allow suspension of the DNR order, the sur-geon would have been free, as a matter of professionalintegrity, to refuse to take the patient to surgery. Commu-nication skills or lacks of are some of the most importantdeterminants of success or failure.

As it stands, the patient’s request that his DNR orderremains in place guides clinical judgment and decisionmaking, and respect for autonomy requires that the pa-tient’s decision be implemented. One possible remedy isto ask the daughter, a health professional, for guidanceabout whether the patient would want his decision toremain in effect, option A. If not, then the DNR ordercould justifiably be suspended, option E. Absent such sur-rogate authorization, option E is ruled out.

In jousting with the reaper, surgeons win surprisingnumbers of jousts, but the tournament is always his.

REFERENCES

1. Jones JW, McCullough LB. Just how far goes DNR? J Vasc Surg2008;48:1630-2.

2. Hoffmann F. Medicus Politicus, sive, Regulae Prudentiae secundumquas Medicus Juvenis Studia sua & Vitae Rationem Dirigere Debet,1738. Leiden: Philip Bonk; 1746.

3. Kouwenhoven W, Jude J, Knickerbocker G. Closed-chest cardiac mas-sage. JAMA 1960;173:1064-7.

4. McCullough LB, Jones JW. Postoperative futility: a clinical algorithm forsetting limits. Br J Surg 2001;88:1153-4.

5. Burkle CM, Swetz KM, Armstrong MH, Keegan MT. Patient anddoctor attitudes and beliefs concerning perioperative do not resuscitateorders: anesthesiologists’ growing compliance with patient autonomyand self determination guidelines. BMC Anesthesiol 2013;13:2.

6. Sanders A, ScheppM, BairdM. Partial do-not-resuscitate orders: a hazardto patient safety and clinical outcomes? Crit Care Med 2011;39:14-8.