DNR in Anesthesia

Historical and Ethical Foundations

• History and ethical considerations:
  • The 1983 report from the President’s Commission for the Study of Ethical Problems in Medicine established that patients are presumed “full code” unless otherwise documented.⁴
  • The Patient Self-Determination Act (1990) established patients’ and surrogates’ legal right to accept or refuse medical treatment, including resuscitation.⁵
  • Historically, DNR orders were automatically suspended during surgery. Current ethical guidance emphasizes individualized reconsideration of DNR orders before anesthesia rather than automatic suspension.⁵
• Patient perspective: autonomy at the end of life
  • Cardiac arrest during anesthesia may be related to reversible iatrogenic causes; therefore, perioperative discussions should clarify whether resuscitation for reversible events aligns with the patient’s goals of care.⁴
  • CPR may prolong suffering or lead to outcomes inconsistent with a patient’s goals of care, reinforcing the importance of individualized perioperative discussions.⁴
  • These ethical principles form the basis for informed consent discussions regarding perioperative management of DNR orders.

Perioperative Reconsideration of DNR Orders

• Patients with DNR orders undergoing procedures requiring anesthesia should undergo “required reconsideration” of resuscitation preferences prior to surgery.
  • When patients have decision-making capacity, they should participate directly in discussions about perioperative modification of their DNR order.
  • When patients lack capacity, discussions should occur with the legally authorized surrogate decision-maker.
• Anesthesiologists play a central role in these discussions because many interventions used in resuscitation (e.g., airway management, vasoactive medications) are also routine components of anesthetic care.⁸
  • Because anesthesiologists often meet patients shortly before procedures, a structured discussion framework can facilitate efficient and informed decision-making.
  • Clarifications regarding which interventions may occur during anesthesia, including airway management, mechanical ventilation, vasoactive medications, and defibrillation.
  • Patients should understand that some interventions considered resuscitative in other settings may be routine components of safe anesthetic care.
  • It should be discussed whether limiting certain interventions may increase the risk of intraoperative complications or patient discomfort.
• The timing and location of DNR reinstatement should be clearly defined before surgery.⁵
• The agreed perioperative DNR plan should be communicated to all members of the surgical, anesthesia, and postoperative care teams.⁵
• Patients with DNR orders may experience differences in care unrelated to CPR; clear perioperative planning helps reduce unintended undertreatment.⁷
• If a clinician has ethical objections to honoring a patient’s DNR preferences during a procedure, alternative providers should be arranged when possible.⁸

Perioperative Management of DNR Orders

• Several approaches may be used to manage DNR orders in the perioperative period depending on patient preferences and goals of care.²
• Common perioperative DNR management strategies are outlined in Table 1.

• The perioperative plan should include when and where the patient’s baseline DNR status will be reinstated.

Documentation and Communication of Perioperative DNR Plans

• Clear documentation of perioperative DNR discussions is essential to ensure patient preferences are respected and communicated across care teams.⁹
• Initial DNR Documentation
  • Document the original DNR order, including the rationale and the patient’s overall goals of care.
• Preoperative Reconsideration
  • Document discussion of DNR status when surgery or anesthesia is planned.
  • Include whether the discussion occurred with the patient or surrogate decision-maker.
• Preoperative Confirmation
  • Document the final perioperative DNR plan immediately before the procedure.
  • Include:
    • Selected management option (e.g., suspension, procedure-directed LAR, goal-directed LAR, or continuation of DNR)
    • Specific permitted or refused interventions
    • Timing and location for reinstatement of baseline DNR status.
• Postoperative Documentation
  • Document reinstatement of the original DNR order or any changes in code status after surgery.
  • Reassess goals of care if clinical status changes.
• The perioperative DNR plan should be clearly communicated to the surgical, anesthesia, PACU, ICU, and ward teams to avoid misunderstandings during transitions of care.
• Palliative care consultation may be helpful for complex goals-of-care discussions or when conflicts arise.