Perioperative considerations of do not resuscitate and do not intubate orders in adult patients

The vast majority of medical orders are for the purpose of some action being taken; for example, orders to admit patients to the hospital and orders to administer medications. DNR (Do Not Resuscitate) and DNI (Do Not Intubate) orders, however, are exceptions to these medical orders that initiate an action. DNR and DNI orders in the perioperative period may pit patients’ rights to decide which actions are (or are not) performed on their bodies against the surgeon and anesthesiologist’s duties to do their best to treat patients and to do no harm. Autonomy figures prominently in Western medical ethics and, especially, in the United States (US). Patients should be able to directly (or through their surrogate) express their wishes for what type(s) of care they wish provided to them. Automatic suspension of DNR orders compromises patients’ abilities to decide their own fate. Surgeons may feel duty-bound by the principle of beneficence to only perform actions that will physically benefit patients and feel, that by requesting surgery, patients implicitly want their surgeon to “get them through” the surgery, no matter what. Such an attitude would preclude letting patients die on the operating room table if they could be saved by cardiopulmonary resuscitation. Anesthesiologists often feel guided by nonmaleficence, going so far as to say that they “don’t want to be a patient’s executioner." Like many of their surgical colleagues, they view standing by while patients die from potentially totally reversible events as being totally antithetical to their calling.