Correspondence  |   July 1997
Response to “Ethical Concerns in Anesthetic Care for Patients With Do-not-resusitate Orders” 
Author Notes
  • Department of Anesthesiology (Berry); Program on Humanities and Technology in Health Care (Heitman), University of Texas-Houston Health Science Center, 6431 Fannin #5020, Houston, Texas 77030.
Article Information
Correspondence   |   July 1997
Response to “Ethical Concerns in Anesthetic Care for Patients With Do-not-resusitate Orders” 
Anesthesiology 7 1997, Vol.87, 174. doi:
Anesthesiology 7 1997, Vol.87, 174. doi:
To the Editor:-We are disappointed but not surprised to read of one institution's efforts to simplify the issue of do-not-resuscitate orders in the perioperative period. [1 ] Although consent for surgery and anesthesia implies consent for all of the component parts, patients may not always agree to conditional interventions (those not normally needed in the conduct of an anesthetic) when these options are clearly presented. The possibility that some patients may refuse specific resuscitative measures continues to distress many anesthesiologists and seems to have prompted some to try to avoid the situation entirely.
Bastron [1 ] dismisses requests for limitations to perioperative resuscitation as a result of unsophisticated patients misunderstanding their own desires. This is an insidious return to paternalism that ignores the possible depth of patients' comprehension and conviction in these matters. Although Bastron rightly emphasizes the importance of discussing the patient's goals, this discussion should include, rather than replace, consent to specific interventions. The “intentional vagueness” of the Scott & White form serves only expediency in the preoperative consent process. Offering two effectively identical choices to a patient is clearly deceptive; both options lead to the same treatment.
In our opinion, there are no “resuscitative” procedures that are “intrinsic” to an anesthetic (even for a laparotomy), and there are certainly none that are non-negotiable. In rejecting the ASA guidelines, Bastron confuses convenience with feasibility. We understand his logistic problems, however, local custom should not preclude doing one's own preoperative visits when decisions critical to patient well-being are involved. There is no obstacle, beyond time, to a clear and concise explanation of any of the ASA-defined procedures [2 ] to allow a patient to make informed choices about all aspects of planned (or unplanned) anesthetic care.
Although patient autonomy is not an absolute principle, it outweighs physician's convenience. If we are to understand ourselves and our motivations, we should examine more fully our discomfort when patient autonomy conflicts with our preferences.
James M. Berry, M.D.
Department of Anesthesiology
Elizabeth Heitman, Ph.D.
Program on Humanities and Technology in Health Care; University of Texas-Houston Health Science Center; 6431 Fannin #5020; Houston, Texas 77030
(Accepted for publication April 24, 1997.)
Bastron RD: Ethical concerns in anesthetic care for patients with do-not-resuscitate orders. Anesthesiology 1996; 85:1190-3.
Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders or Other Directives That Limit Treatment, 1995, American Society of Anesthesiologists.