Role of DNRs in Elderly Patients’ Outcomes Analyzed

Dealing with surgical illness in patients with a DNR advanced directive presents both ethical and clinical challenges. In my experience many patients create such advanced directives out of a desire to not have a prolonged attempt at rescuing them from complications of surgery with little chance of either survival or more importantly, meaningful survival. In spite of these wishes, many are willing to have treatment that runs the risk of creating just such a situation.

A typical example is an elderly patient with a DNR advanced directive, living independently with a reasonable quality of life who presents with a large AAA needing treatment to prevent rupture. If postoperative complications occur requiring a prolonged stay in the ICU on the ventilator, pressers etc.both the surgeon and the next of kin or health care proxy can find themselves in a difficult moral dilemma of doing everything possible to give the patient the best chance of a successful outcome while at the same time not violating the spirit of their advanced directive.

The crux of such a dilemma is being able to identify the point when recovery is no longer likely, which is difficult. When a patient is a DNR, it may well be that surgeons and the family will err on the side of withdrawing support sooner than in a patient without such a directive, which may partially explain the findings of this study. It that sense, it may be a self fulfilling prophecy but is that really such a bad thing? I personally think it is not.

Doing what's best for the patient, which includes, respecting their wishes includes knowing when to stop.

Frank Pomposelli, M.D., is Chairman of Surgery, St. Elizabeth’s Medical Center, Boston, Mass. He is also an associate medical editor of Vascular Specialist.