"Suspend the DNR in the OR - that's standard, right?"

"No - automatic suspension is an old habit, not a standard."

The current ethical framework is required reconsideration: the directive is neither automatically suspended nor automatically applied. It is reviewed with the patient or surrogate, deliberately, before anesthetizing.

The reasoning:

• The OR is an environment where arrest is usually iatrogenic and reversible - hypoxia, a vagal response, medication effect, a blocked tube. That is the argument for full resuscitation during the anesthetic.
• But the patient's values, not the venue, determine the limits. She is septic and dying of metastatic cancer. Her POLST says comfort-focused. Honoring that is not a technical problem; it is the point.
• Do not withhold reversible treatment in the meantime. The DNR does not mean withholding fluids, antibiotics, vasopressors, or source control - all of which are aimed at getting her home. Declining those unilaterally would be abandoning her goals.
• Involve the surrogate formally. Her daughter's statement - "if there was a chance she could get back home" - is a goal, not a code status. It needs to be converted into concrete interventions.

This requires a real conversation, not a hallway nod.

Document a procedure-specific code status, intervention by intervention. Vague statements like "full code in the OR" are the frequent source of conflict.

Specify:

• Permitted: fluids and blood products, vasopressors, antibiotics, airway support, and - because she is DNI - decide explicitly whether intubation is permitted as a time-limited trial. Note the option of a spinal or general anesthetic with an LMA to avoid the DNI conflict entirely, weighed against the profound vasodilation a neuraxial in septic shock would cause.
• Defibrillation and chest compressions: permitted, or limited?
• Duration limits: for example, "if there is no return of spontaneous circulation after a defined period, or if it becomes clear that survival with an acceptable quality of life is not achievable, we stop" - a time-limited trial.
• Postoperative limits: ICU admission for a defined trial versus comfort-focused care only.

People: the patient's surrogate decision-maker, the surgeon, the anesthesia team, the intensivist who will receive her, and the bedside nurse. Involve the ethics committee or palliative care when there is disagreement or when the surrogate's statements conflict with the written POLST. Record who said what, when, and in whose words.

Nothing about the code status changes what I do right now, because this is not cardiac arrest.

Frame it correctly: this is a hemodynamic consequence of septic shock plus anesthetic-induced vasodilation and myocardial depression. It is reversible.

Act:

1. Lower the anesthetic depth immediately - induction was too deep for this patient; deepen again once she is stable.
2. Fluids and vasopressors early: balanced crystalloid bolus, then norepinephrine or push-dose vasopressor. Choose a rate and pressure target, not "the highest possible."
3. Reconsider the differential: could this be an anaphylactic reaction to an antibiotic given at induction? Then treat with epinephrine and fluids. Is she bleeding? Is the airway pressure high?
4. Reassess the goals: if she is now requiring escalating vasopressors simply to survive the anesthetic, that is exactly the information the surrogate needs in real time. Pausing the case and speaking to her is legitimate and wise.

The code status is engaged only if she arrests or requires an intervention that the documented plan prohibits. Until then, the plan is resuscitation, and it is consistent with her stated wish to have a chance of going home.