Management of DNR Orders During Surgery
The DNR order should be temporarily suspended during surgery and the immediate perioperative period, then reinstated postoperatively after discussion with the patient or surrogate. 1, 2, 3, 4
Rationale for Suspension (Option B)
Intraoperative cardiac arrest has fundamentally different characteristics than ward-based arrests, making resuscitation highly appropriate even in DNR patients. 1, 2, 3
Perioperative cardiac arrests typically result from readily reversible causes including cardiovascular response to anesthesia induction, vagal responses to surgical manipulation, hypoxia, hypovolemia, and hemorrhage. 1, 2, 3
Survival rates for intraoperative cardiac arrest are substantially higher than other settings due to continuous monitoring and immediate presence of trained personnel allowing instant detection and treatment. 1, 2, 3
The American Heart Association explicitly states that DNR orders are recommendations rather than legally binding directives, allowing clinical judgment in emergency situations. 3, 4
Required Preoperative Process
Before surgery, the anesthesiologist and surgeon must review the DNR order with the patient or surrogate to determine its applicability during the perioperative period. 3, 4
Document the discussion explicitly, including the rationale for DNR suspension and the specific timeframe (during surgery and immediate recovery). 3, 4
Clarify that DNR suspension does not mean withholding appropriate anesthetic care, blood products, antibiotics, or procedural interventions—it specifically addresses cardiopulmonary resuscitation in the event of arrest. 4
Patients expect this discussion to occur before the day of surgery and believe they should have input into the decision. 5
Critical Distinctions During Surgery
Several interventions are NOT considered CPR and are not prohibited by DNR orders, even if the order were to remain in effect: 1, 2
Chest compressions to expedite drug circulation in low cardiac output states (distinct from cardiac arrest). 1, 2
Use of cardiac arrest algorithm drugs (epinephrine, atropine, antiarrhythmics) to treat bradycardia, hypotension, or arrhythmia during anesthesia. 1, 2
Defibrillation or synchronized cardioversion for suddenly occurring arrhythmias. 1, 2
Postoperative Management
Once the patient is stabilized and has capacity (or when surrogates are available), explicitly discuss when the DNR order should be reinstated. 2, 4
Document the circumstances under which the DNR order is brought back into force. 2, 4
The temporal scope of DNR suspension must be clearly specified—typically it covers the operative procedure and immediate recovery period. 4
Common Pitfalls to Avoid
The most critical error is assuming a pre-existing DNR order automatically applies in the OR without prior discussion. 3
Never automatically continue DNR orders during surgery without patient-specific discussion and documentation. 6, 7
Never automatically suspend DNR orders without informing the patient or surrogate—this violates patient autonomy. 6, 7
Do not assume DNR means "do not treat"—patients with DNR orders should receive all other appropriate medical and surgical interventions unless explicitly indicated otherwise. 1, 4
Why Options A and C Are Inappropriate
Option A (keeping DNR during surgery) is inappropriate because it fails to account for the high reversibility of perioperative cardiac arrest and denies patients potentially life-saving intervention for iatrogenic, treatable causes. 1, 2, 3
Option C (permanently canceling DNR even after surgery) is inappropriate because it violates patient autonomy and fails to respect the patient's wishes for end-of-life care in non-surgical contexts where the risk-benefit calculation differs substantially. 4, 5