title: Anesthesiologist management of perioperative do-not-resuscitate orders: a simulation-based experiment.
abstract: BACKGROUND
  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.
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA. David.Waisel@childrens.harvard.edu
authors.forename: David B
authors.initials: DB
authors.lastname: Waisel
authors.forename: Robert
authors.initials: R
authors.lastname: Simon
authors.forename: Robert D
authors.initials: RD
authors.lastname: Truog
authors.forename: Hemanth
authors.initials: H
authors.lastname: Baboolal
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Raemer
mesh_terms: D000776:Anesthesiology / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D016544:Patient Simulation; D010818:Practice Patterns, Physicians'; D015397:Program Evaluation; D016414:Resuscitation Orders; D011795:Surveys and Questionnaires