Ethical Considerations if Patient Undergoing Surgery or Invasive Procedures Has DNR Order

By Stacey Kusterbeck

Compliance for code status management for patients undergoing invasive procedures with do not resuscitate (DNR) orders is surprisingly low, notes Emily Rivet, MD, MBA, a colorectal surgeon at VCU Health. To address this, Rivet and colleagues created a workflow for code status management for inpatients with DNR orders undergoing cardiac catheterization or electrophysiology procedures.¹ The researchers used the process to temporarily rescind DNR orders for 32 patients undergoing cardiology procedures. “We were very surprised by the number of patients with DNR code status undergoing invasive cardiac procedures,” says Rivet.

More than one-third (37.5%) of the patients were undergoing the procedure specifically to extend their life. “The wish to avoid resuscitation from unexpected medical events can coexist with the desire to undergo planned elective interventions to extend life,” stresses Rivet.

Stakeholders appreciated the clarity and efficiency of the workflow. “A fundamental lesson of this project is to involve a multidisciplinary team in these types of efforts, particularly nursing staff,” says Rivet. “It is important to recognize the challenges in operationalizing abstract ethical principles in the busy environment of an academic hospital. There may have to be a balance between what is ideal care and feasible care.”

Anesthesiologists and patients (or their representatives) should reconsider DNR orders preoperatively instead of de facto rescinding the DNR order, according to longstanding guidelines from the American Society of Anesthesiologists (ASA).² “The tension that everybody feels is when you are going for a surgery, that surely invalidates your choice of choosing not to be resuscitated. That’s because everybody conflates DNR with ‘do not treat.’ But those are two very different things,” says Michael Souter, MB, ChB, DA, FRCA, FNCS, chair of the ASA’s Committee on Ethics.

The ASA guidelines were followed by similar recommendations from the American College of Surgeons and the Association of periOperative Registered Nurses.^3,4 All of the guidelines emphasize that patient choice is the most important consideration in this scenario. If a patient had a DNR order but is coming to the operating room, healthcare providers should discuss whether the fact that the patient is having surgery changes the patient’s perspective in any way. “Most people make their choices in the context of cardiac arrest outcomes out in the street, which are very different from cardiac arrest outcomes in the hospital and are radically different from cardiac arrest outcomes during surgery,” observes Souter. “It is important for patients to understand that. If, once you have had that discussion, the patient’s choice remains the same, then our position has always been that you stand by that.”

Some members of the ASA Ethics Committee questioned whether the ASA’s policy on DNR orders perioperatively truly reflected anesthesiologists’ practices. The ASA Committee on Ethics surveyed 2,366 members.⁵ Only about 40% of anesthesiologists were aware of the ASA guidelines. Of these respondents, 91.1% reported finding the guidelines useful. More than 70% of anesthesiologists reported having institutional policies on DNR orders. Most had used those policies at least once. Most institutional policies mentioned goals of care used to determine resuscitation elements and patient selection of acceptable elements of resuscitation.

The respondents also were asked who was involved in discussions of DNR perioperatively — whether it was the anesthesiologist or whether it was left to others in the hospital. About three-quarters of respondents indicated that they were involved in perioperative discussions. Other respondents noted that others were involved in these discussions, including hospital representatives, palliative care, and nursing. “That doesn’t point to the unique perspective that the anesthesiologist has in these situations. If resuscitation is required, it is the anesthesiologist that directs that because that’s where our area of expertise is,” asserts Souter.

More than one-fourth of the policies mentioned automatic rescindment of DNR orders. “Not every physician seems to be on the same page with regard to how we treat DNR and issues of patient choice,” says Souter. About 4% of anesthesiologists said that the patient would not be informed in that situation. Respondents were asked what they would do if a patient wanted to maintain the DNR order, but the clinician felt it was inappropriate. Most anesthesiologists said they would honor the patient’s wishes, but 16.8% said they would transfer care and 9% would refuse to administer anesthesia. “It’s a small percentage, but a troubling one. Although most anesthesiologists would go along with the patient’s wishes, there was still a persistent minority who said, ‘I don’t believe in what you asked for, so I’m not going to do that,’ and wouldn’t necessarily transfer care to others. This is one of the growing concerns that we see in medical practice — and this is not unique to our specialty. But it’s one that we see reflected consistently, which is the tension between one’s own moral beliefs and the duty of care that you owe to the patient in supporting their decisions,” says Souter.

The study findings point to the need for greater awareness of the guidelines and careful consideration of the ethical issues in these cases. “We’re not saying everybody has to get in line with identical thinking. But it’s important that one discuss this with colleagues. If you are personally opposed to limitation of care in those types of settings, based on the patient’s instructions, then you need to let your colleagues know. You need to have a strategy for dealing with this, so we are not just riding roughshod over the patient’s perspective,” says Souter.

Sometimes patients forget to mention that they have a DNR, it goes unnoticed during pre-operative discussions and is only discovered when the patient actually comes in for surgery. “That is not a great setting to explore the attitudes that people have, but that’s the environment we’re in. It’s part of the duty of the anesthesiologist to have that discussion with the patient. Because it matters to the patient at the end of the day,” says Souter.

In some cases, there can be conflicting views among healthcare providers on how to proceed. A surgeon may refuse to operate unless the DNR is rescinded, for example. “That should lead to an ethics consult,” says Souter. The ethicist, being detached from any personal stake in the situation, can lead clinicians to the right thing to do in terms of respecting the patient’s autonomy.

Another group of researchers assessed outcomes in patients with DNR orders undergoing urological surgery.⁶ “Prior to our study, several studies had shown that patients with DNR orders have worse postoperative outcomes than full-code patients,” notes Benzad Abbasi, MD, the study’s lead author and a research fellow in the UCSF Department of Urology. However, those data largely came from non-urologic populations, with different procedures, indications, and risk profiles. Abbasi and colleagues set out to answer the question: Does simply having a DNR order put urologic patients at higher perioperative risk, even after accounting for how old or sick the patient is and what kind of operation they are having?

The researchers compared outcomes of 245 patients with documented DNR orders with 234 matched controls. “We anticipated higher mortality, but the magnitude and pattern were still notable,” says Abbasi. Thirty-day mortality was more than twice as high in DNR patients compared with matched full-code controls (14% vs. 6%), even though both groups needed cardiopulmonary resuscitation (CPR) or ventilatory support at about the same rate. This difference was especially pronounced after minor, non-emergent procedures that typically are considered relatively low-risk. DNR patients also had more minor complications, especially urinary tract infections, and stayed in the hospital longer, even though the rates of major complications were about the same.

“Taken together, these findings suggest DNR status is not just a shorthand for ‘sicker patients.’ It appears to shape how aggressively teams monitor for, escalate, and treat complications once they occur. In practice, the DNR label seems to shape how patients are managed throughout the perioperative course, not just at the moment when CPR is on the table,” says Abbasi.

A DNR order is intended to limit CPR in the event of cardiopulmonary arrest. It is not a blanket instruction to avoid other indicated treatments, such as antibiotics, fluids, or transfer to higher levels of care. “Yet, in practice, some team members treat DNR as ‘no escalation.’ Others implicitly assume that a DNR patient is less invested in their own survival. Both attitudes can contribute to slower recognition and treatment of complications and to a ‘failure-to-rescue’ pattern,” says Abbasi.

Surgeons need to consider whether it is ethically justifiable to offer or proceed with a low-benefit operation when the real-world risk for DNR patients is higher, says Abbasi. “That means being upfront with patients and families about this added risk, making sure the DNR label does not quietly lower the intensity of perioperative care, and keeping consent conversations very clear about what may actually happen,” says Abbasi. Preoperative discussions should connect the goals of surgery to the patient’s values and lay out a specific perioperative code-status plan. Everyone should understand in advance which interventions are and are not consistent with the patient’s wishes, says Abbasi.

Ethicists can address this issue at their institutions in these ways, offers Abbasi:

• Educate healthcare providers that DNR is a focused limitation on CPR, not a directive to do less across the board. “Teaching sessions for surgery, anesthesia, nursing, and hospital medicine can highlight how misinterpreting DNR status may contribute to under-recognition of deterioration and delayed escalation,” says Abbasi.
• Help to develop perioperative DNR policies. This entails moving away from automatically suspending DNR orders in the operating room and, instead, requiring documented preoperative discussions about goals of care and code status and offering structured options. For example, patients may decide to accept short-term intubation but not chest compressions or prolonged life support. “Integrating these expectations into pre-op workflows and checklists makes it more likely they will be followed,” says Abbasi.
• Support difficult cases through early consultation. When teams are unsure whether surgery is appropriate for a DNR patient or when there is disagreement about how far to escalate care if complications arise, ethics consultation can help clarify values, align expectations, and mediate conflict.
• Partner with quality and safety teams to review outcomes for surgical patients with DNR orders and identify patterns of under-escalation or variability in practice.

“Ethicists can also help create patient-facing materials that explain what DNR means in the context of anesthesia and surgery,” says Abbasi. This facilitates code-status decisions that are informed, realistic, and aligned with patient goals while preserving a high standard of perioperative care.

Inpatient DNR orders are not always respected for these reasons, according to Thaddeus Mason Pope, JD, PhD, HEC-C, professor of law at Mitchell Hamline School of Law in Saint Paul, MN:

• Clinicians may be unaware of the order (either because it was not clearly documented or because they negligently failed to notice it even when it was clearly documented).
• Clinicians sometimes resuscitate patients despite their known DNR orders. “A growing number of courts recognize this as actionable medical malpractice,” warns Pope.
• Even though DNR orders apply only to CPR, many clinicians erroneously infer that they also apply to other forms of treatment.

DNR orders also are common outside the hospital or clinic setting. Many seriously ill patients have physician orders for life-saving treatment (POLST) or out-of-hospital DNR orders. “These may not be respected because they are not found,” says Pope. For example, the orders may be on the patient’s refrigerator or in a state registry.

In the prehospital setting, DNR orders present some unique ethical concerns. “When EMS [emergency medical services] is called to a patient in cardiac arrest, decisions about whether to start or withhold resuscitation must be made within seconds. Yet, there is no standardized approach to recognizing or honoring DNR orders in the prehospital setting,” says Satheesh Gunaga, DO, an emergency care physician at Henry Ford Health. Gunaga and colleagues analyzed the variation of DNR documentation in 63 EMS protocols in 50 U.S. cities.⁷ “The degree of variability was more substantial than we expected,” reports Gunaga.

Although most EMS systems have DNR protocols, they vary widely in what documentation they consider valid. This ranges from advance directives to living wills to POLST forms to DNR bracelets to verbal statements from family members. Some systems require direct medical oversight before honoring a verbal DNR, while others do not mention verbal DNRs at all. “Only a minority of systems accept out-of-state DNR forms, which is concerning for patients who travel or live near state borders. This lack of standardization creates real ethical tension in the field. It increases the risk of either unwanted resuscitation, or hesitation to act when a patient might benefit,” says Gunaga.

“Although this study focused on EMS, there are significant implications upstream and downstream of prehospital care,” says Gunaga. For hospital clinicians — particularly those involved in serious illness care, hospice transitions, and discharge planning — clear communication across care settings is an important consideration. “When a patient with a serious illness is being discharged home or to a facility, clinicians should confirm that their resuscitation preferences are formalized in a way EMS can honor. This helps reduce the likelihood of unwanted resuscitation attempts and minimizes distress for families,” says Gunaga.

Ethicists can help ensure that patient autonomy and values continue to guide care even in unpredictable out-of-hospital emergencies in these ways, says Gunaga:

• Advocate for institutional standardization. Ethicists can help evaluate whether current resuscitation documentation aligns with what EMS actually can use in the field. “They can promote adoption of standardized, EMS-friendly documentation such as POLST,” says Gunaga.
• Strengthen education for clinicians and families. Many people assume that a hospital DNR order automatically applies outside the hospital, which often is not the case. “Ethicists can work with clinical teams to improve counseling around the limitations of certain documents,” says Gunaga.
• Promote equitable access to goal-concordant care. The study findings show that where a patient lives directly influences whether their wishes will be honored. “Ethicists can help institutions recognize and address this inequity, advocate for policy improvements, and encourage broader acceptance of verbal or surrogate-communicated DNR preferences when appropriate,” says Gunaga.

Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.

References

1. Fisher C, Noreika D, Yu KR, et al. Structured workflow to manage periprocedural code status for patients with do-not-resuscitate orders. Am Surg. 2026;92(1):293-298.

2. American Society of Anesthesiologists. Statement on ethical guidelines for the anesthesia care of patients with do-not-resuscitate orders. Reaffirmed Oct. 13, 2023. https://www.asahq.org/standards-and-practice-parameters/statement-on-ethical-guidelines-for-the-anesthesia-care-of-patients-with-do-not-resuscitate-orders

3. American College of Surgeons. Statement on advance directives by patients: “Do not resuscitate” in the operating room. Published Jan. 3, 2014. https://www.facs.org/about-acs/statements/advance-directives-by-patients-do-not-resuscitate-in-the-operating-room/

4. Association of periOperative Registered Nurses (AORN). AORN position statement on perioperative care of patients with do-not-resuscitate or allow-natural-death orders. AORN J. 2020;112(4):392-395.

5. Hadler RA, Curry SE, Hendrix JM, et al. A survey of practice and attitudes toward “do not resuscitate” orders among practicing anesthesiologists in the United States. Anesth Analg. 2025;141(3):485-488.

6. Abbasi B, Frankiewicz M, Hakam N, et al. The impact of do-not-resuscitate orders on outcomes of urological surgeries. Urol Pract. 2025;12(5):613-621.

7. Breyre AM, Merkle-Scotland EJ, Yang DH. Do not resuscitate (DNR) emergency medical services (EMS) protocol variation in the United States. Am J Emerg Med. 2025;97:123-128.