Anesthesia Student Survival Guide.pdf - Index of

ethicAl And leGAl issues in AnesthesiA ● 499
appoints another individual to make decisions on behalf of the patient should
he/she become incapacitated. It does not provide specific guidance as to what
those decisions should be.
Do Not Resuscitate (DNR)/Do Not Intubate (DNI)
Some patients will choose to forgo life saving treatments, such as intubation
or CPR. Typically this decision is made near the end of a patient’s life or by
a patient with a terminal illness. Keep in mind that patients have the right to
choose whether or not resuscitative measures should be instituted in case of
cardiac arrest.
These choices (DNR/DNI) are not automatically placed on hold should a
patient come for surgery. It is therefore imperative that a discussion regarding
a patient’s specific preferences be initiated prior to coming into the operating
room. In this discussion, the patient should be asked to outline which therapies
are acceptable and which are not during the operative period. Treatments typically
discussed include intubation, CPR, defibrillation, and vasopressors. The
outcome of the discussion and the patient’s choices should be (1) clearly documented
in the chart, and (2) communicated to the entire operative team.
Case Study
An 80-year-old man has terminal colon cancer. He has metastatic disease
with liver and brain metastases. As his condition worsened over the preceding
year, he had several conversations with his family and physicians about his
end of life care. He has a signed and witnessed advanced directive indicating
his desire to be treated as “DNR/DNI” (do not resuscitate, do not intubate). He
has now developed bowel obstruction and was admitted with severe abdominal
pain. His surgeons have recommended a diverting colostomy for palliative
care. They obtained consent for the operation from the patient last night, but
anesthesia consent has not yet been obtained. The patient was medicated with
hydromorphone and is now somnolent and falls asleep immediately upon
waking. The surgeons are eager to operate before the bowel ruptures.
Can you obtain informed consent from the patient? Is surgical consent sufficient?
What options do you have?
A somnolent, barely arousable patient can probably not give informed consent.
Just waking up the patient long enough to obtain his signature on the