Anesthesia Department Policy Regarding Advanced Directives

Formerly Considerations for Policy Development Number 4.1

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Certified Registered Nurse Anesthetists (CRNAs) have the ethical obligation to uphold the rights of patients. Procedural interventions requiring anesthesia services may be indicated for a patient with an advanced directive, or a do-not-resuscitate order.1  The presence of an advanced directive for a patient may pose moral and ethical dilemmas for both the patient and the CRNA.  Bioethical principles2 for decision making, including those underlying the Patient Self Determination Act3, establish the patient’s right to make decisions about his or her care. CRNAs have obligations under these principles which may create bioethical dilemmas when faced with a patient’s choices for care.4-6 

The purpose of an advanced directive is to communicate a patient’s decisions for care, and these choices may be modified at any time.7-8  Often the directive will include end-of-life decisions such as cardiopulmonary resuscitation or tracheal intubation.  Therapeutic interventions germane to anesthesia practice (e.g., endotracheal intubation, controlled ventilation, administration of fluids and vasoactive drugs) may conflict with a patient’s advanced directive. The tradition of automatic rescission of an advanced directive must be replaced with one of "required reconsideration."9-12 Although challenging to implement13, required reconsideration involves discussion with the patient or his/her proxy if the patient is no longer capable of independent decision making, as well as other healthcare professionals involved with the patient’s care.14-15  The required reconsideration process supports the patient’s decisions and requires adequate time, sensitivity and respectful dialogue. This process also provides all parties the opportunity to share information and clarify any misunderstandings about the goals of palliative surgical procedures and anesthesia care.4-5, 16-17  The discussion should be documented in the patient’s chart and any decisions communicated to subsequent providers.  Documentation should include a summary of the agreed plan of care, the parties involved in the discussion, and the circumstances under which the advanced directive order is to be restored, if aspects of the directive are suspended during the procedural period.  If the decision is made to retain the advanced directive during anesthesia care, the specific therapeutic anesthetic interventions that are to be withheld must be understood and documented in the patient’s chart. If the CRNA is not willing to honor the patient’s choices, then the CRNA should facilitate the transfer of the patient’s anesthesia care to a colleague who can abide by the patient’s requests.18  A facility’s ethics committee may serve as a resource for resolving issues and supporting the patient’s right to self-determination.19-20

Similar to the adult patient, the pediatric patient must be afforded the same process of required reconsideration when an advanced directive exists. A child often will be aware of his or her current health status, and have specific opinions regarding his or her care. When it is appropriate, the child’s assent21 regarding his or her care should be captured during the required reconsideration process.10,22


  1. Perioperative Care of Patients with Do-Not-Resuscitate or Allow-Natural-Death Orders. Association of periOperative Registered Nurses. Denver: CO. 2009.
  2. Devlin B, Magill G. The process of ethical decision making. Best Pract Res Clin Anaesthesiol 2006;20:493-506.
  3. Patient Self Determination Act 1990 (Public Law 101-508 §§4206, 4751).
  4. Jackson SH, Van Norman GA. Goals- and values-directed approach to informed consent in the "DNR" patient presenting for surgery: more demanding of the anesthesiologist? Anesthesiology 1999;90:3-6.
  5. Truog RD, Waisel DB, Burns JP. DNR in the OR: a goal-directed approach. Anesthesiology 1999;90:289-95.
  6. Waisel D, Jackson S, Fine P. Should do-not-resuscitate orders be suspended for surgical cases? Curr Opin Anaesthesiol 2003;16:209-13.
  7. Berlandi JL, Duncan J. Perioperative DNR Orders, Palliative Surgery, and Ethics. Perioperative Nursing Clinics 2008; 3(3):223-32.
  8. The Joint Commission.  Comprehensive Accreditation Manual for Hospitals.  Glossary. Jan 2010.
  9. Cohen CB, Cohen PJ. Do-not-resuscitate orders in the operating room. New England Journal of Medicine. 1991; 325:1879-1882.
  10. Fallat ME, Deshpande JK. Do-not-resuscitate orders for pediatric patients who require anesthesia and surgery. Pediatrics 2004;114:1686-92.
  11. Guarisco KK. Managing do-not-resuscitate orders in the perianesthesia period. J Perianesth Nurs 2004;19:300-7.
  12. Margolis JO, McGrath BJ, Kussin PS, Schwinn DA. Do not resuscitate (DNR) orders during surgery: ethical foundations for institutional policies in the United States. Anesth Analg 1995;80:806-9.
  13. Waisel DB, Simon R, Truog RD, Baboolal H, Raemer DB. Anesthesiologist management of perioperative do-not-resuscitate orders: a simulation-based experiment. Simul Healthc 2009;4:70-6.
  14. Burns JP, Edwards J, Johnson J, Cassem NH, Truog RD. Do-not-resuscitate order after 25 years. Crit Care Med 2003;31:1543-50.
  15. Coopmans VC, Gries CA. CRNA awareness and experience with perioperative DNR orders. AANA J 2000;68:247-56.
  16. Ewanchuk M, Brindley PG. Perioperative do-not-resuscitate orders--doing 'nothing' when 'something' can be done. Crit Care 2006;10:219.
  17. Waisel DB, Burns JP, Johnson JA, Hardart GE, Truog RD. Guidelines for perioperative do-not-resuscitate policies. J Clin Anesth 2002;14:467-73.
  18. Code of Ethics. American Association of Nurse Anesthetists. Park Ridge: IL. 2005.
  19. Clemency MV, Thompson NJ. Do not resuscitate orders in the perioperative period: patient perspectives. Anesth Analg 1997;84:859-64.
  20. McGraw KS. Should do-not-resuscitate orders be suspended during surgical procedures? AORN J 1998;67:794-6, 9.
  21. American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-7.
  22. Baker JN, Rai S, Liu W, Srivastava K, Kane JR, Zawistowski CA, Burghen EA, Gattuso JS, West N, Althoff J, Funk A, Hinds PS. Race does not influence do-not-resuscitate status or the number or timing of end-of-life care discussions at a pediatric oncology referral center. J Palliat Med 2009;12:71-6. 


Adopted by AANA Board of Directors June 1994 and June 2010.