UK anaesthetists could face accusations of euthanasia or assisted suicide if they follow Do Not Attempt Resuscitation (DNAR) Orders duringaccording to an editorial in the July issue of Anaesthesia.

Patients who have surgery often need routine interventions during anaesthesia that could be classed as resuscitation, points out Consultant Anaesthetist Dr Michael McBrien from the Royal Victoria Hospital in Belfast, Northern Ireland.

But automatically suspending DNAR Orders during surgery is no longer an acceptable option, according to Dr McBrien and his editorial co-author, Dr Gary Heyburn, Associate Specialist Orthogeriatrician at the Hospital.

"If the anaesthetist were to proceed and strictly obey the general understanding of a DNAR order under such circumstances, it could possibly be construed as an act of euthanasia or assisted suicide" they stress.

McBrien and Heyburn say that UK clinicians urgently need national guidance on how to manage the growing number of DNAR orders, pointing out that American guidelines have been in place since 1993.

"It is surprising that no guidelines or serious discussions on this matter have appeared in the UK to parallel the developments in North America" adds Dr McBrien.

The need for guidelines has been given added impetus by the fact that the Mental Capacity Act is due to come into force next year and that the European Convention on Human Rights is now enshrined in UK Law. From 1 April 2007, the Act will give formal legal recognition to the patient's right to make advance decisions about the care they receive and reinforce the common law position about DNAR Orders that already exists.

"The paternalistic primary ethical principal of the past, namely immediate medical benefit to the patient, has been overtaken" says Dr McBrien.

"If we are not to face litigation in the future we must read, understand and implement what the law requires from us in this area."

Clinicians also need clear guidance about how to handle requests made by parents of sick children or relatives of patients not deemed legally competent.

"Usually agreement will be reached about whether cardiopulmonary resuscitation should be attempted if the patient suffers respiratory or cardiac arrest" says Dr McBrien.

"If disagreement persists despite attempts to reach agreement, legal advice should be sought. "Parents cannot require doctors to provide treatment contrary to their professional judgement, but doctors will try to accommodate parents' wishes as far as is compatible with protecting the child's interest."

With individual clinicians facing increasing dilemmas on numerous fronts the need for clear local and national guidelines has never been greater. "A review of the basic ethical principles involved is needed to decide how individual anaesthetists and anaesthetic departments in the UK should manage this situation" conclude the authors.

"Dr McBrien and Dr Heyburn have done patients a service in stimulating discussion about the relationship between modern - and often quite complex - DNAR orders and the interventions required during anaesthesia" says the Journal's Editor-in-Chief Dr David Bogod, Consultant Anaesthetist at Nottingham City Hospital, UK.

"The issue actually extends to wider aspects of medical practice by anaesthetists, including intensive and palliative care. While individual autonomy in these cases is often best served by a sensitive and detailed exploration of the patient's wishes by the doctors caring for them, it might be that some national guidance is needed.

"The Council of the Association of Anaesthetists of Great Britain and Ireland have advised us that they are actively considering setting up a working party for this purpose."

-- Editorial. 'Do not attempt resuscitation' orders in the per-operative period. Michael McBrien and Gary Heyburn, Royal Victoria Hospital, Belfast. Anaesthesia. Volume 61, pages 625-627. (July 2006).

-- Anaesthesia, which was established in 1945, is the official journal of the Association of Anaesthetists of Great Britain and Ireland. It publishes original, peer-reviewed articles to an international audience on all aspects of general and regional anaesthesia, intensive care and pain therapy, including research on equipment. Consultant Anaesthetist Dr David Bogod of Nottingham City Hospital, UK, is Editor in Chief of the journal, which is published by Blackwell Publishing Ltd. blackwellpublishing/ana

-- In June 2006 Anaesthesia was named the highest ranked anaesthetic journal in Europe and the fifth highest worldwide (out of 22) by the prestigious ISI Journal Citation Reports ®. These reports evaluate the world's leading journals and their impact and influence on the global research community. They cover 7,000 highly cited, peer reviewed journals in approximately 200 disciplines.