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Anesthesiologist Management of Perioperative Do-Not-Resuscitate Orders: A Simulation-Based Experiment

Waisel, David B. MD; Simon, Robert EdD; Truog, Robert D. MD; Baboolal, Hemanth MD; Raemer, Daniel B. PhD

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: Summer 2009 - Volume 4 - Issue 2 - pp 70-76
doi: 10.1097/SIH.0b013e31819e137b
Empirical Investigations

Introduction: This study was performed to assess perioperative reevaluation of Do-Not-Resuscitate (DNR) orders by practicing anesthesiologists.

Methods: As part of an Anesthesia Crisis Resource Management course, an anesthesiologist interviewed a patient-actor with prostate cancer and bone metastases scheduled for a central venous catheter placement. The chart included a properly documented DNR order and the patient-actor's scripted responses emphasized that he would accept resuscitative efforts only “if the adverse clinical events were believed to be both temporary and reversible.” Later, the subject assumed responsibility for the anesthesia in which the patient subsequently developed an iatrogenically induced pneumothorax, became apneic, and had a cardiovascular arrest requiring a prolonged resuscitation. Responses to these events and a following survey were evaluated.

Results: Fifty-seven percent of the subjects (17/30) addressed resuscitation during the preoperative interview; 27% (8/30) decided to suspend the DNR order and 30% (9/30) instituted a goal-directed or procedure-directed DNR order. Ninety percent (27/30) of the groups chose to continue resuscitative efforts until the simulation ended. Of the surveyed participants, over 90% would place a chest tube, intubate the trachea, do chest compressions, and perform cardiac defibrillation. Common reasons for intervening were reversibility, iatrogenicity, and that intervention would be consistent with the patient's goals.

Conclusions: Inadequacies in perioperative reevaluation of DNR orders existed at all stages. Simulation of perioperative DNR orders is a useful way to elicit anesthesiologist's actions in the heat of the moment, which may bring us closer to understanding the actions of anesthesiologists during clinical practice.

From the Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts (DBW, RDT); Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts (RS, HB, DBR); Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts (DBW, RS, RDT, HB, DBR); and Center for Medical Simulation (RS, DBR), Cambridge, Massachusetts.

Reprints: Dr. David B. Waisel, Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA (e-mail:

The authors have indicated that they have no conflicts of interest to disclose.

© 2009 Lippincott Williams & Wilkins, Inc.