Date of Award

August 2022

Degree Type

Dissertation

Degree Name

Doctor of Philosophy

Department

Nursing

First Advisor

Jeanne M Erickson

Committee Members

Daniel Goldstein, Natalie S McAndrew, Lucy L Mkandawire-Valhmu

Keywords

Anesthesia, Case Study, Do Not Resuscitate, Emancipatory Compassion, Foucault, Poststructural

Abstract

Current practice recommendations suggest mandatory reconsideration of pre-existing Do Not Resuscitate (DNR) orders and other directives limiting care when adults undergo surgery with anesthesia. However, many perianesthesia clinicians believe that these policies are inappropriate and difficult to implement, and patients may have unclear expectations about anesthesia, creating discord between patients and clinicians. Research about what discourses dominate how patients and clinicians talk about advanced directives in the perianesthesia setting, and how those discourses relate to power-knowledge is limited. This inquiry, guided by the emancipatory theory of compassion, used Foucauldian poststructural case study design and contextualizing analysis to explore this problem. Data were collected through interviews and observations of patients with existing advance directives who underwent surgery, family members, and perianesthesia clinicians who participated in their care. Twenty-seven participants completed the observation and interview components, and eighteen additional participants agreed to observation only. Four authoritative discourses were identified. The “We’ll just suspend the DNR…” discourse permeates perianesthesia culture and produces a will among clinicians to automatically suspend the limiting directive. Other discourses related to a lack of time for discussion, a desire not to talk about advance directives unless essential to care, and confusion about who is responsible to address the limiting directive. The investigation found that patients talked about functional outcomes as stopping points for resuscitation while clinicians talked about intervention-based stopping points, making meaningful communication challenging between groups. Finally, the inquiry demonstrated support for the theory of emancipatory compassion and provided qualitative evidence to support the theory’s key conceptual elements. These results suggest that even where policies of mandatory advance directive reconsideration exist, patients may experience environments that constrain their choices. Strategies to address power-knowledge inequity should be implemented when developing advance directive policies or making practice decisions.

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