• Brown Sydney E S SES Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesia and Critical Care, , Ryan M Antiel, Thane A Blinman, Susanna Shaw, Mark D Neuman, and Chris Feudtner.
• Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address: sydneyesbrown@gmail.com.
• J Pain Symptom Manage. 2019 May 1; 57 (5): 971-979.

ContextDo-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period are limited.ObjectivesTo evaluate perioperative management of DNR orders at a tertiary care children's hospital.MethodsWe reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from February 1, 2016, to August 1, 2017. Using standardized case report forms, we abstracted the following from physician notes: 1) patient/family wishes with respect to the DNR, 2) whether preoperative DNR orders were continued, modified, or suspended during the perioperative period, and 3) whether life-threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision-making in the perioperative period.ResultsTwenty-three patients aged six days to 17 years had a DNR order in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures and suspended for 15 (51%). Three children (13%) suffered life-threatening events. We identified four time points in the perioperative period where systematic reconsideration should be documented in the medical record, and identified recommended personnel involved and important discussion points at each time point.ConclusionOpportunities exist to improve how DNR orders are managed during the perioperative period.Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

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