Authors: Hadler RA, et al.
Anesthesia & Analgesia 141(3): 485-488, September 2025. doi:10.1213/ANE.0000000000007450
This national ASA survey assessed anesthesiologists’ awareness, use, and attitudes toward guidelines on perioperative “Do Not [Attempt to] Resuscitate” (DN[A]R) orders. Among 28,431 members, 2,366 responded (8.3%). Just 38.7% were aware of the ASA guidelines, though most of those familiar with them found them helpful. Seventy-one percent reported institutional DN(A)R policies, with wide variation in how policies were applied.
Despite existing guidance emphasizing reconsideration rather than automatic suspension of DN(A)R orders, 28.1% of respondents reported automatic rescindment as part of their institution’s or their own practice. In hypothetical scenarios, most anesthesiologists supported goal-directed discussions with patients or surrogates, but up to 36.4% indicated they would rescind DN(A)R orders when patients were unresponsive. Notably, 9.1% of anesthesiologists said they would refuse to provide anesthesia if patient wishes conflicted with their personal view, while 16.8% would transfer care.
What You Should Know:
Significant variability persists in how anesthesiologists approach perioperative DN(A)R orders, with concerning rates of automatic rescindment and refusal to honor patient autonomy. This reflects knowledge gaps, ethical tensions, and institutional inconsistencies that may compromise patient-centered care.
Clinical Relevance:
For practicing anesthesiologists, this study highlights the importance of proactively discussing DN(A)R orders with patients or surrogates, respecting autonomy, and aligning with ASA and ACS guidance. Institutions should provide clear, consistent policies and education to prevent automatic rescindment and to support ethically sound perioperative practice.
References
Guideline/consensus
Authors: American Society of Anesthesiologists.
Statement on Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders. Accessed August 19, 2024. https://www.asahq.org/standards-and-practice-parameters/statement-on-ethical-guidelines-for-the-anesthesia-care-of-patients-with-do-not-resuscitate-orders
Authors: American College of Surgeons.
Statement on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room. Accessed August 19, 2024. https://www.facs.org/about-acs/statements/advance-directives-by-patients-do-not-resuscitate-in-the-operating-room/
Authors: 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;112:392–395.
Supporting evidence
Authors: Burkle CM, et al.
BMC Anesthesiol 2013;13:2. doi:10.1186/1471-2253-13-2
Authors: Nurok M, et al.
J Clin Anesth 2014;26:174–176. doi:10.1016/j.jclinane.2013.09.013
Thank you to Anesthesia & Analgesia for allowing us to use this article.