When You Need To Have Surgery.

A LETTER TO OUR PATIENTS WITH ADVANCE DIRECTIVES
.from your operating room doctors and nurses who care,

Your primary care physician, at your request, has written an order that you wish to wear your "DNR: Comfort Care" or "DNR Comfort Care Arrest" bracelet both during and after your care at The Cleveland Clinic Foundation. This bracelet, your doctor's order in the chart and the advanced directives which you have signed inform all of your physicians and nurses how you have chosen to be cared for during the latter stages of your illness. We want you to know that your doctors and nurses understand and respect your wishes and desire to make you comfortable while providing World Class Care during your stay with us.

Many patients, just like you, have asked us how the DNR: Comfort Care status will affect the decisions of your physicians during any operative procedures which you may need to insure your comfort and help you feel better. We have prepared this brochure to help you to understand the options available to you when you need surgery at The Cleveland Clinic Foundation. Once you have read and understood this brochure, there will be three options for you to discuss with your doctors. You and your loved ones might want to give some thought to these options should surgery be needed.

TO HELP YOU UNDERSTAND ANESTHESIA AND SURGERY:

Many patients are not aware of the difference between resuscitation and what an anesthesiologist does when administering general anesthesia. In each situation, the patient is generally unconsious. In both situations, intravenous (IV) lines are started. In both situations, medications may be necessary to increase a patient's blood pressure or to treat an abnormal heart rhythm. And in both situations, meticulous attention to a patient's airway (the way a patient is helped to breathe effectively) is vital to the success of the anesthetic or the success of a resuscitation.

Because most patients do not know how to distinguish between giving anesthesia and resuscitation, we would like to help you understand which parts of a patient's advance directives can be honored during anesthesia and which advance directives are essential to the success of the anesthesia itself. Please discuss this with your doctors if this is difficult for you to understand.

DNR Comfort Care directives tell all health care workers that they must not:

  1. start an intravenous line (IV)
  2. insert an artificial airway
  3. provide respiratory assistance
  4. initiate cardiac monitoring
  5. administer resuscitative drugs
  6. administer chest compressions
  7. defibrillate or cardiovert

We will proceed with one of these seven issues at a time.

STARTING AN IV:

An intravenous line (IV) is standard practice before any operation can be started. Intravenous lines are used to administer medication, like pentothal, to permit a pleasant induction to anesthesia. Many other medications are given during an anesthetic, including pain medicines and special medicines to prevent nausea and vomiting. An IV is essential to prevent dehydration in patients how have had to fast for eight or more hours before their operation. The IV is used for many purposes while the patient is under anesthesia and is discontinued after a patient has regained consciousness, is comfortable, and is able to take fluids by mouth. An IV is considered essential to the success of the anesthesia and surgery, and attempting surgery without one is, in most situations, impossible.

BREATHING FOR THE PATIENT:

Many patients do not realize that many anesthesia medications slow down or completely stop a patient's ability to breathe for himself. Anesthesiologists are trained to "breathe for the patient" with a breathing bag and mask and by inserting special breathing tubes during the time when anesthesia medications are being given. Once the patient wakes up after surgery, breathing for the patient is no longer necessary, and the breathing tubes and special airways are removed.

It is important that our patients understand that anesthesia is quickly reversible, and that most breathing tubes are removed before a patient is awake enough to remember having one. While anesthesia medications gases are being given to the patient, special breathing equipment is essential for the safety and success of the anesthesia and surgery.

DO I NEED TO HAVE A BREATHING TUBE?

Patients have told us that one of their greatest fears is to be separated from their families in the last few weeks to months of their lives. Patients with advance directives have expressed concern that they might have a breathing tube preventing them from being able to talk to their loved ones. The breathing tube, especially if a ventilator is needed to keep a patient breathing, would force our patients to spend precious days in the hospital and away from the people they love.

We want our patients to know that your physicians and nurses would not chose to spend the end of our own lives this way. Our wishes and plans for you are the same plans we would want for our own families and for ourselves in the same situation.

When a patient becomes unconscious because of anesthesia, he or she is not only unable to breathe for themselves, but they cannot cough or protect their lungs from stomach acids which can regurgitate to the back of their throats during surgery. The breathing tube prevents this acid from getting into the lungs and making a patient sicker. It also permits excellent oxygenation of the patient when he/she is under the influence of anesthesia drugs. It is an anesthesiologist's duty to protect our patients when they cannot protect themselves while unconscious from anesthesia. In most circumstances your anesthesiologist will remove the breathing tube as soon as you are awake.

Breathing tubes are not always necessary, but when they are needed to protect the patient from breathing in stomach contents or from a swollen airway, they are used only after a patient is asleep and removed as a patient is waking up. Only in rare cases are breathing tubes kept in for another hour or two while the patient is in the recovery room. Most patients are unaware that a breathing tube was ever used. Your doctors have no plans for a breathing tube to remain after an anesthetic, except in the rare case that it might be needed for a few more hours after surgery.

For your anesthesiologist's purposes, any breathing tube is temporary and only in certain types of surgery is it considered essential to the success of the anesthesia and surgery.

IS A VENTILATOR NECESSARY?

Ventilators are used during an operation for the convenience of the anesthesiologist. Ventilators free the anesthetists' hands for purposes of giving medications, keeping operative records and giving fluids during surgery. Ventilators are also used to administer anesthetic gases and can be used to optimize a patient's oxygen level while he or she is unconscious. In rare circumstances a ventilator may be needed for an hour or two after an operation while a patient's body is eliminating anesthesia medications. Use of a ventilator is temporary and is not needed once the patient has fully recovered from the anesthesia.

WHY DO MY DOCTORS NEED TO TAKE MY BLOOD PRESSURE AND MONITOR MY HEART?

In the same way that a pilot uses monitors on an airplane to make decisions about wind velocity and direction, altitude and changes in the weather, anesthetists use monitors to make certain that a patient is breathing well and is not "too deep" or too lightly anesthetized. Also, monitors help anesthetists to know how anesthesia medicines and the surgery itself have affected blood pressure or heart rhythm. Monitors help your anesthetist prevent heart attacks, strokes, and inadequate oxygen levels. Monitors even help to prevent awareness under anesthesia! Monitors are all removed once a patient is recovered from anesthesia medicines. Use of monitors are temporary and considered essential to the safety and success of the anesthesia and surgery.

IF I NEED SURGERY TO MAKE ME MORE COMFORTABLE, WILL MY DOCTORS IGNORE MY ADVANCE DIRECTIVES?

No. You have made a legal and binding decision that you desire to spend your remaining days at home, if possible, with loved ones supporting you and caring for you. Your advance directives are clearly understood and will be honored by your doctors and nurses at The Cleveland Clinic Foundation. During the time you are unconscious from anesthesia medication, your doctors will ask your permission to perform those interventions that are considered standard of care, temporary, reversible and necessary to protect you during your operation.

At your request, the surgery team will agree not to perform chest compressions, defibrillation or perform cardiopulmonary resuscitation (CPR), should an arrest situation occur during surgery.

IF YOU NEED TO HAVE SURGERY, PLEASE REVIEW THE FOLLOWING INSTRUCTIONS YOU WOULD PREFER YOUR DOCTORS AND NURSES TO FOLLOW DURING YOUR OPERATION:

OPTION ONE: I would like all advance directives to be discontinued during anesthesia and surgery and fully reinstated once I am discharged from the recovery room. If I Were to have a cardiopulmonary arrest during surgery, I would want my doctors to use their clinical judgement if they were reasonably sure that CPR would be quickly successful and that, in their judgement, I would be unlikely to have permanent disability from their efforts. If in their judgment they felt that CPR would not have a successful outcome, I would ask that all CPR be withheld.

OPTION TWO: I would like to have my advance directives continued but modified during surgery and my immediate recovery. I refuse CPR, but I will permit those measures: medication, airway issues and monitoring, which are considered essential for a safe and successful outcome from anesthesia and surgery. I would ask that my DNR: Comfort Care advance directives be fully reinstated upon my discharge from the recovery room.

Essentially, I am consenting to the following:

a. monitoring of ECG, blood pressure, oxygenation, exhaled gases and vapors and any intraoperative monitors which are considered essential for a good outcome;

b. temporary manipulation of my airway and breathing with breathing tubes and ventilators, when needed; and with orders that I will be breathing on my own without these devises before discharge from the recovery room;

c. use of special drugs to increase my blood pressure or correct an abnormal heart beat if these were caused by anesthesia medicines or surgical manipulation, can be immediately corrected, and are not given in the doses used during cardiopulmonary resuscitation.

I refuse to permit:

a. chest compressions;

b. defibrillation of my heart;

c. use of techniques or large doses of resuscitative drugs which would be considered CPR.

OPTION THREE: I request no changes be made in my DNR: Comfort Care orders. If surgery is absolutely necessary, I permit use of the following:

____an IV ____anesthesia medicine ____breathing equipment ____fluids ____pain medicine ____medicine to stop nausea ____monitors ____breathing tube ____ventilator ____blood ____blood components ____heart/blood pressure medicine

Thank you for taking the time to review this brochure. Your understanding of these issues may help you when you discuss these issues with your doctors.

© 2005 The Cleveland Clinic Department of Bioethics | Contact Us | Privacy | Disclaimer | Last modified: 08/16/2005