Management of DNR Orders in the Perioperative Period
DNR orders should be reviewed and discussed before surgery, with the decision to suspend, maintain, or modify the order made collaboratively with the patient or surrogate, rather than automatically suspending or continuing the order. 1
Required Preoperative Discussion
The American Heart Association explicitly mandates that DNR orders must be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate to determine their applicability in the operating suite and during the immediate postoperative recovery period. 1 This is not optional—it is a required reconsideration that must occur for every patient with a preexisting DNR order. 1
Key Elements to Address in the Discussion
Clarify the scope of resuscitation: Specify which interventions are withheld (chest compressions, defibrillation, intubation, mechanical ventilation, vasopressors) and which continue (anesthesia, blood products, antibiotics, procedural interventions). 1
Distinguish procedural interventions from resuscitation: Many anesthetic interventions (intubation, mechanical ventilation, vasopressor administration) are routine components of anesthesia care but may overlap with resuscitative measures, requiring explicit clarification. 1
Document the decision: The attending physician must write a note explaining the rationale for DNR suspension, continuation, or modification, with explicit instructions for the perioperative period. 1
Why Automatic Suspension is Inappropriate
There is no justification for either automatic suspension or automatic continuation of DNR orders in patients undergoing surgery. 2 The assumption by many anesthesiologists that DNR orders are automatically suspended is problematic and underestimates patient autonomy. 3
The Ethical Framework
Respect for patient autonomy is paramount: Patients retain the right to refuse specific interventions even during surgery, and this right cannot be unilaterally overridden by clinicians. 1, 2
Context matters: The appropriateness of DNR suspension depends on whether the surgery is curative/life-prolonging versus purely palliative, and whether cardiac arrest would likely result from reversible procedural causes versus progression of underlying terminal disease. 4, 2
Three Acceptable Approaches
Based on the discussion with the patient or surrogate, three options exist:
Option 1: Full Suspension During Surgery
- Appropriate when: The patient desires the benefits of surgery and accepts that perioperative cardiac arrest is often due to reversible anesthetic or procedural causes with high survival rates. 4
- Reinstate timing: Specify when the DNR order will be reinstated (e.g., upon arrival to recovery room, after extubation, or after a defined time period). 1, 4
Option 2: Procedure-Directed Approach
- Appropriate when: The patient wants specific interventions withheld even during surgery but accepts others necessary for the procedure itself. 1
- Requires explicit documentation: List exactly which interventions are refused (e.g., chest compressions and defibrillation) versus accepted (e.g., vasopressors, intubation for airway management). 1
Option 3: Full Continuation of DNR
- Appropriate when: The patient prioritizes comfort and quality of remaining life over life extension, even if death occurs during or immediately after a palliative procedure. 1, 2
- Requires clear documentation: Confirm that all parties understand the patient may die during surgery from an otherwise reversible cause. 1
Critical Distinction: What DNR Does NOT Prohibit
A DNR order does not automatically preclude interventions such as administration of parenteral fluids, nutrition, oxygen, analgesia, sedation, antiarrhythmics, or vasopressors, unless these are explicitly included in the order. 1 The designation relates only to cardiopulmonary arrest, and patients should receive all other appropriate medical and surgical interventions. 1
Common Pitfalls to Avoid
Assuming DNR means "do not treat": DNR status should not limit appropriate medical and surgical interventions unless explicitly indicated. 1
Failing to document the discussion: Oral DNR orders or modifications are not acceptable—all decisions must be written with clear rationale. 1
Not specifying the temporal scope: Clearly document when a suspended DNR order will be reinstated (e.g., "DNR suspended from induction until 24 hours postoperatively"). 1, 4
Unilateral decision-making: The decision cannot be made by the anesthesiologist alone—it requires collaboration with the surgeon, patient/surrogate, and ideally the primary care physician. 1, 3
Postoperative Management
After surgery, the DNR order status must be explicitly addressed again. 1 If the DNR was suspended, document when and under what circumstances it will be reinstated. 4 If complications occur, reassess goals of care with the patient or surrogate before making decisions about ongoing aggressive treatment. 1
Answer to the Multiple Choice Question
The correct answer is: None of the provided options are universally appropriate. The most appropriate management requires a patient-specific discussion before surgery to determine whether to suspend, modify, or continue the DNR order based on the patient's values and goals of care. 1, 2 However, if forced to choose from the options provided, Option B (put DNR on hold and continue after surgery) most closely aligns with common practice, though this should never be done automatically without discussion. 1, 4