Statement on advance directives by patients: “Do Not Resuscitate” in the operating room

The Board of Regents of the American College of Surgeons approved a revised [ST-19] Statement on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room, at the Board’s meeting in October 2013. The revised statement was developed and submitted by the Committee on Ethics. The original statement was published in the September 1994 Bulletin.

It is generally expected that the surgeon will assume primary responsibility for advising patients regarding risks, benefits, and alternatives when discussing a potential operation.1 This policy focuses on patients who accept a surgeon’s recommendation to have surgery and who already have in place an advance directive, specifically, a “Do Not Resuscitate” (DNR) order. The best approach for these patients is a policy of “required reconsideration” of the existing DNR orders.2 Required reconsideration means that the patient or designated surrogate and the physicians who will be responsible for the patient’s care should, when possible, discuss the new intraoperative and perioperative risks associated with the surgical procedure, the patient’s treatment goals, and an approach for potentially life-threatening problems consistent with the patient’s values and preferences.

Some patients with DNR status become candidates for surgical procedures that may provide them with significant benefit, even though the procedure may not change the natural history of the underlying disease. Examples include procedures to treat intestinal obstruction in individuals with advanced malignancy and surgical procedures such as amputation to alleviate pain or prevent progression of underlying illness.

When such patients who have DNR orders in place undergo surgical procedures and the accompanying sedation or anesthesia, they are subjected to new and potentially correctable risks of cardiopulmonary arrest. Furthermore, many of the therapeutic actions employed in resuscitation (for example, intubation, mechanical ventilation, and administration of vasoactive drugs) are also an integral part of routine anesthesia management, and it is appropriate that the patient be so informed.

Policies that lead either to the automatic enforcement of all DNR orders or to disregarding or automatically cancelling such orders do not sufficiently support a patient’s right to self-determination.3-5 An institutional policy of automatic cancellation of DNR status in cases where a surgical procedure is to be carried out removes the patient or the patient’s duly authorized representative from appropriate participation in decision making. Automatic enforcement of DNR orders without discussion and clarification may not adequately inform patients or their authorized representatives about the new risks associated with surgery and anesthesia and may lead to inappropriate perioperative and anesthetic management.

The required reconsideration discussion should occur as early as practical after a decision is made to have surgery. This discussion may result in the patient agreeing to suspend the DNR order during surgery and the perioperative period, retaining the original DNR order, or modifying the DNR order. Required reconsideration works best when the patient has decision-making capacity and when time is available for a conversation. However, even in urgent situations or when the patient lacks decision-making capacity, the surgeon can usually discuss the situation with the patient’s designated surrogate. In emergency situations, it may be impossible or impractical for the surgeon to speak with the patient or the patient’s duly authorized representative prior to the patient’s approaching demise, when irreversible damage occurs, or similar circumstances. In such situations, the surgeon must use his or her best judgment as to what the patient would wish.

Once a decision is reached on the patient’s DNR status as a result of the required reconsideration conversation, the surgeon must continue his or her leadership role in the following areas: (1) documenting and conveying the patient’s advance directive and DNR status to the members of the operating room team; (2) helping the operating room team members understand and interpret the patient’s advance directive; and (3) if necessary, finding an alternate team member to replace an individual who has an ethical or professional conflict with the patient’s advance directive instructions.6
State law and institutional policies may also impact DNR orders and must be taken into account in determining the appropriate course of action.


  1. Joint Commission on Accreditation of Healthcare Organizations. Manual of the Joint Commission on Accreditation of Health Care Organizations. Patient Rights Chapter. Chicago, IL: JCAHO; 1994.
  2. Cohen CB, Cohen PJ. Required reconsideration of “Do-Not-Resuscitate” orders in the operating room and certain other treatment settings. Law Med Health Care. 1992;20(4):354-363.
  3. AORN position statement: Perioperative care of patients with Do-Not-Resuscitate or Allow-Natural-Death Orders. 2009. Available at: Accessed September 11, 2013.
  4. American Society of Anesthesiologists. Ethical guidelines for the anesthesia care of patients with Do-Not-Resuscitate orders or other directives that limit treatment. 2008. Available at: Accessed November 18, 2013.
  5. American College of Surgeons. Statement of the American College of Surgeons on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room. Bull Am Coll of Surg. 1994;79(9):29.
  6. Demme RA, Singer EA, Greenlaw J, Quill TE. Ethical issues in palliative care. Anesthesiol Clin. 2006;24(1):129-144.

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