A DNR Order in a Patient Booked for Hip Fracture Fixation
A 79-year-old woman with metastatic pancreatic cancer (ECOG performance status 2) is admitted with a displaced femoral neck fracture after a fall. She has a documented 'do not attempt resuscitation / do not intubate' order completed four months ago, and her daughter is her healthcare proxy. She is alert, oriented, and scores 28/30 on the Mini-Mental State Examination. Pain is 8/10. She says clearly that she wants the operation because she 'does not want to lie in bed in pain and be a vegetable'. The on-call anaesthetist writes in the notes that 'DNR status is automatically suspended in theatre' and schedules a general anaesthetic for the morning list. Her potassium is 5.6 mmol/L, creatinine 190 µmol/L, and haemoglobin 88 g/L. The orthopaedic registrar is pressing for the case to go first on the list because of pressure on trauma beds.
1. Critique the statement that DNR status is automatically suspended in theatre and describe how you would conduct the perioperative resuscitation discussion.
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The statement is wrong and it is a substitute for thinking. There is no automatic suspension of a DNR order in theatre. Professional guidance (including Association of Anaesthetists guidance) is that the order should undergo required reconsideration before surgery. Automatic suspension overrides the patient's autonomy, may result in unwanted CPR, and - just as importantly - lets the team avoid the conversation that actually needs to happen.
How I would conduct the discussion:
- Establish what she understands about her illness, her prognosis and what she means by 'being a vegetable'. Her own words should guide the framing.
- Explain why the perioperative period is different: anaesthesia itself can cause reversible arrest (anaphylaxis, local anaesthetic toxicity, hypoxia, vagal bradycardia) where full resuscitation can succeed and return her to her current state. Arrest from progression of her cancer or a massive pulmonary embolism is different, and CPR has a very low chance of a meaningful recovery.
- Offer a menu of options, not a binary:
- continue the full DNR/DNI order;
- modify it - allow intubation, ventilation, vasopressors, fluids and blood, but not chest compressions;
- suspend it for a defined period (theatre and recovery only), reverting afterwards;
- suspend it fully.
- Involve her daughter, the palliative care team and the surgical team; document the exact agreement in her notes and on the resuscitation form, and brief the whole theatre team at the safety huddle.
- Anything agreed must be procedure-specific and time-limited, and revisited if she deteriorates.
2. What are the elements of valid informed consent in this situation, and what specific risks and outcomes should you discuss?
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Capacity first. She is alert, oriented, scores 28/30 and can express a consistent choice - she has capacity, and her decision takes precedence over her daughter's proxy view while she retains it. Capacity is decision-specific and should be documented, not assumed.
Elements of valid consent:
- The diagnosis and the proposed procedure - and the alternative: conservative management with traction and analgesia, which carries high rates of non-union, pressure injury, prolonged immobility and pain.
- Material risks and benefits: for hip fracture surgery in this population, 30-day mortality is in the region of 5–10%, with the recognised benefits of better pain control, earlier mobility and probably improved survival compared with non-operative management.
- The anaesthetic options: spinal versus general, with the trade-offs (spinal avoids airway instrumentation but causes sympathectomy and hypotension; general is required if she cannot lie still or is coagulopathic).
- The DNR plan agreed above - the patient must know what will and will not be done if she arrests.
- The realistic prognosis from metastatic pancreatic cancer, and that the goal of surgery is comfort and function, not cure.
Optimization before theatre (consent does not replace this): treat K⁺ 5.6 mmol/L, assess and correct volume status and the creatinine rise, transfuse to a threshold of about 70–80 g/L with cardiac risk, prescribe VTE prophylaxis with attention to timing around neuraxial block, and involve palliative care for pain and goals-of-care support.
Document the discussion in the patient's own words, with the daughter's involvement and the names of everyone present.
3. If she sustains a cardiac arrest during induction from a suspected pulmonary embolism, what would you do, and does your action depend on how the discussion was documented?
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Conduct is determined by the documented agreement - which is exactly why the agreement must exist before induction.
If the plan documented a modified order (for example, intubation and vasopressors allowed, chest compressions not permitted): I follow it. That means releasing the surgeon, stopping the procedure, giving analgesia and sedation for comfort, informing the family and allowing a natural death in theatre or recovery. I would not initiate compressions.
If the plan documented a suspended order for the duration of the case: full resuscitation, including compressions, with the arrest managed as any other - and if massive pulmonary embolism is suspected and there is echocardiographic evidence of right ventricular strain, thrombolysis may be considered, though in metastatic cancer with a likely poor outcome this is not realistic.
If there is no documented plan - which is the failure this case is designed to expose - the default is to act in the patient's best interests, which generally means preserving life in the moment unless there is clear and reliable evidence she would not want that. I would start resuscitation while a second person retrieves the notes, contacts the proxy and confirms the DNR order. Once the valid order is confirmed, the decision to stop is made.
The teaching point: an arrest during induction from an anaesthetic cause and an arrest from massive pulmonary embolism can look identical in the first thirty seconds. That is precisely why the discussion must separate reversible anaesthetic events from progression of her underlying disease, and why the decision must be on the chart and in the team briefing before the patient enters the room.