Page 33 - CASA Bulletin of Anesthesiology 2019 Issue 6

Vol.6, No.6, 2019

Periop DNR Order PBLD

Q1: Quick question . Do we always rescind patient’s DNR order in the OR ? Or we can actually continue
that if patient agrees with it . ( 胡向天 )
1 . Just encountered similar case. My attending confirmed with the patient including defibrillation before
time-out . (Christian Ayfred)

2 . We have a periop order to rescind the DNR/DNI . (Zhang Yang)

3 . I am trying to see what if pt wants to continue DNR in OR . How we deal with that? ( 胡向天 )

4 . DNR includes DNI by definition…… (翔崽响铛铛)

5 . We had a short procedure and pt confirmed DNR but was ok with defib. (Christian Ayfred)

6 . I did a pleural case for a stage IV lung cancer patient . He wanted to keep his DNR/DNI, knowing the
risk that case may be aborted if he could not tolerate the procedure under sedation. He was okay with fluid/
blood and medication resuscitation, but did not want chest compression, defib or intubation. I discussed this
with my attending and we both agreed it was reasonable to continue his DNR/DNI with specifics listed as
above . Unfortunately a different attending did the case on the day of surgery and he freaked out and told patient
that he would not do the case unless he rescinded DNR/DNI . Patient did, case went ok with sedation but I still
feel that patient was coerced . (Fiona Chen)

7 . My patient is a 76 year old female coming for femur fracture TFN (The Titanium Trochanteric Fixation
Nail) who has a history of right posterior epidermoid tumor herniated into her cerebellum . She was deemed
non operative by a tertiary medical center for the brain tumor given the patient’s complex medical history . She
suffered severe mental status change on the way in to our ER after she fell and broke her femur . She was not
awake, alert and oriented till this afternoon when I saw her . And she stated clearly to me about the DNR issues .
Anything except reversible anesthesia meds induced VITAL CHANGES won't be accepted including defib,
chest compression etc . I had to call risk management and call for a family meeting emergently to talk about
exactly what happened in OR and how we did things in standard of care . She still wanted to remain DNR . Just
so hard to see patient wanted to continue their DNR order and it also places a huge burden on our shoulders . It
is like patient's wish to go . But why agreeing for a surgery while you are having a herniated tumor in brain . Just
don't understand . ( 胡向天 )

8 . Basically, even going to surgery, we cannot automatically suspend the DNR . We have to discuss with the
patient in detail of what is acceptable from the patient . Some patients will refuse intubation no matter what . (汪
红)

9 . Agreed. We always discuss with the patient first. My a few encounters with DNR/DNI patients were all
hospitalized patients, and surgical team usually did a good job in telling the pts about temporary rescind of their
code status, we had no issues with the code status, but as anesthesiologists per institutional protocol, we need to
further discuss with the pt and place an periop order to suspend DNR/DNI . (Zhang Yang)

10 . Our OR has re-evaluation sheet for DNR, to confirm or reorder each item for intraop. The sheet will be
signed by either patient or family before OR, even if there is no changes . We had someone refused intubation
and the case was canceled without choices . (Xiaoyan)

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