What is the most appropriate approach for a patient with a pre-existing Do Not Resuscitate (DNR) order undergoing surgery?

Management of DNR Orders During Surgery

The most appropriate approach is Option B: DNR orders should be reviewed and discussed preoperatively, with the decision typically involving temporary suspension during surgery followed by reinstatement postoperatively, based on a collaborative discussion with the patient or surrogate that clarifies which interventions are acceptable during the perioperative period. 1

Mandatory Preoperative Discussion

DNR orders must be reviewed before surgery through a collaborative discussion involving the anesthesiologist, attending surgeon, and patient or surrogate to determine the order's applicability during surgery and immediate postoperative recovery. 1 This is not optional—it is an explicit mandate. 1

The discussion must clarify:

• The scope of resuscitation, specifying which interventions are withheld versus continued (such as anesthesia, blood products, antibiotics, and procedural interventions). 1
• The distinction between procedural interventions and resuscitation, as many anesthetic interventions overlap with resuscitative measures and require explicit clarification. 1
• Documentation of the decision with a physician's note explaining the rationale for DNR suspension, continuation, or modification, with explicit instructions for the perioperative period. 1

Three Acceptable Management Approaches

The guidelines recognize three ethically acceptable options, each requiring explicit patient consent: 1

1. Full Suspension During Surgery (Most Common)

• 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. 1
• This recognizes that intraoperative arrests differ fundamentally from arrests in terminally ill patients—they are typically iatrogenic and highly reversible. 1

2. Procedure-Directed Approach (Selective Suspension)

• Appropriate when the patient wants specific interventions withheld even during surgery but accepts others necessary for the procedure itself. 1
• Requires explicit documentation of which interventions are refused versus accepted. 1
• This allows nuanced decision-making aligned with patient values. 1

3. Full Continuation of DNR (Rare)

• 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
• Requires clear documentation that all parties understand the patient may die during surgery from an otherwise reversible cause. 1

Critical Distinctions to Avoid Common Pitfalls

It is wrong to automatically suspend DNR orders in the perioperative period. 2 It is equally wrong to automatically continue DNR orders in the perioperative period. 2 Both approaches violate patient autonomy and fail to account for the unique context of surgery. 3, 2

A DNR order does not automatically preclude interventions such as parenteral fluids, nutrition, oxygen, analgesia, sedation, antiarrhythmics, or vasopressors unless these are explicitly included in the order. 1, 4 Assuming "DNR means do not treat" is a dangerous pitfall—DNR status should not limit appropriate medical and surgical interventions unless explicitly indicated. 1

The temporal scope of any suspended DNR order must be explicitly documented, including when and under what circumstances it will be reinstated. 1 Failing to address this creates dangerous ambiguity in postoperative care. 1

Postoperative Management

After surgery, the DNR order status must be explicitly addressed again, with documentation of when and under what circumstances it will be reinstated if it was suspended. 1 This cannot be left to assumption—it requires active decision-making and clear documentation. 1

Special Context: Pre-existing DNR Orders

Patients with pre-existing DNR orders are specifically included in the requirement for preoperative discussion and reconsideration. 1 The principle of "required reconsideration" applies to all DNR orders when surgery is planned. 2 This ensures that the DNR order reflects the patient's current wishes in the specific context of surgical intervention. 3, 2

Evidence Quality Note

These recommendations are based on consensus guidelines from the American Heart Association and American College of Cardiology, synthesized in high-quality guideline summaries. 1 While older guidelines from stroke management recommend postponing new DNR orders early in hospitalization for conditions like intracerebral hemorrhage 5, these recommendations specifically address new DNR orders in acute illness, not the perioperative management of pre-existing DNR orders, which is a distinct clinical scenario requiring the collaborative approach outlined above. 1