The Preprinted "DNR Suspended in the OR" Order

No - automatic suspension is not acceptable, and "policy" is not a justification.

Why automatic suspension is wrong:

• It extinguishes a decision the patient made deliberately, at the moment he is least able to speak for himself, without his consent or his surrogate's. That is a direct affront to autonomy.
• It is also unnecessary. Most of what happens in an anesthetic - intubation, vasoactive infusions, fluid resuscitation - is routine treatment, not resuscitation. Suspending DNR wholesale conflates the two and makes the patient's stated wishes invisible to the team caring for him.

Why automatic continuation is also inadequate:

• Some interventions used in the OR are formally resuscitation (chest compressions, defibrillation), and some anesthetics constrain the patient in ways he could not have anticipated when he signed the form. The anesthesiologist cannot claim ignorance of what the patient wanted.

The accepted approach: required reconsideration. The professional consensus of both anesthesiology and surgery is that DNR status in the perioperative period requires an individualized, documented conversation - with the patient if he has capacity, otherwise with the surrogate - that clarifies which specific interventions he would accept for a limited, defined period and which he would refuse. The output is not a yes/no answer but a written, category-specific plan:

• Accepted: endotracheal intubation for the duration of the case and emergence, vasopressors, fluids and blood, antiarrhythmics, defibrillation.
• Declined: chest compressions, prolonged ACLS, ICU admission, re-intubation after a failed extubation.
• Time-limited trial with a defined reassessment point, and explicit restoration of the original DNR/DNI status on leaving the OR.

I would not proceed on a preprinted suspension order. I would speak with the daughter, document the conversation, and put the plan in the chart where the whole team can see it.

How I would actually ask it - concrete, in a way a family member can answer, not abstract:

• "Your father has paperwork saying he does not want CPR. We respect that completely. My question is about a narrower situation: if his heart stopped during surgery for a reason we could fix - say, bleeding we could control or a reaction to a drug - would he want us to do chest compressions and shock his heart to get him through that? Or would he want us to let him go?"
• "He will need a breathing tube for the operation. Would he want us to keep him on the breathing machine for a few hours afterward in the recovery room, or only for the operation itself?"
• "If he needed medicines to keep his blood pressure up during surgery, is that something he would accept?"
• "Who else should be part of this decision?"

What I would document:

• Who I spoke with, their authority to act, the date and time, and who was present at the bedside during the call.
• The patient's stated goals and the surrogate's interpretation of them.
• A category list: accepted - intubation for the duration of the procedure and emergence, vasopressors, fluids and blood, antiarrhythmics, defibrillation for a treatable arrest; declined - chest compressions, prolonged ACLS, ICU admission, re-intubation after extubation failure.
• The time-limited trial and a named clinician to reassess.
• The instruction to reinstate the original DNR/DNI orders on arrival in the recovery area, with a named person responsible for doing it.
• A note that the surgeon and nursing team were informed and that all agree.

This takes ten minutes and prevents the worst outcome: a chaotic resuscitation in a dying man whose wishes nobody can locate.

Right now: it does not restrict me at all, and it should not.

• This is a predictable anesthetic-induced perturbation with an immediately reversible cause, not a cardiac arrest. Treating it is routine anesthesia care, not resuscitation, and withholding treatment here would be both clinically wrong and contrary to what the patient asked for when he accepted anesthesia.
• Actions: stop or lighten the anesthetic, 100% oxygen, small aliquots of phenylephrine or ephedrine, an anticholinergic for the bradycardia, a small fluid bolus if he is hypovolemic from sepsis, and recheck the pressure. Then diagnose the cause: sepsis-related vasodilation and hypovolemia are far more likely here than an intrinsic cardiac problem.
• The correct frame of mind: the accepted categories on the plan (vasopressors accepted; compressions declined) were written for exactly this reason - so that I can treat aggressively and quickly without a debate at the head of the bed.

Same event during transport: the code status describes what is permitted when there is a true arrest - no compressions, no prolonged ACLS. It does not license standing by during hypotension. I would treat the hypotension with the same vasopressors and fluids, and I would have a portable monitor and a bag-valve with me. If he then arrested in transport and the documented plan declines compressions, I would honor it, call for help and for the surrogate, keep him comfortable, and document the sequence and the timing.

The professional obligation: the plan must travel with the patient. My note must state explicitly that DNR/DNI resumes in the PACU and who is responsible for entering the order there. A plan documented only in the OR record is a plan that does not exist at 03:00.