For seriously ill children, some parents choose to get a do-not-resuscitate order, which says that hospital staff won't try to resuscitate the child after his or her heart stops. But DNR orders are written assuming that the heart will stop because of the child's illness. Things are more complicated in surgery, when anesthesia drugs come into play; a new report from the American Academy of Pediatrics gives guidance to doctors who handle these orders.

What the writers wanted to know: What are anesthesiologists' and surgeons' attitudes toward do-not-resuscitate orders in surgery? What should physicians do about children who have DNR orders and are having surgery?

What they did: The writers surveyed anesthesiologists and surgeons in the American Academy of Pediatrics about surgery and DNR orders. They also reviewed the medical literature about how DNRs apply in surgery.

What they found: Most surgeons and anesthesiologists said they'd been asked to operate on or give anesthesia to children with do-not-resuscitate orders. Most said they discuss the resuscitation with the parents of children with DNR orders before surgery, but many said their hospital didn't have a policy on how to handle DNR orders in surgery.

Before surgery, patients (or, in the case of children, their parents) have to give informed consent, in which they agree that they understand the risks of surgery. The writers say that, for a child who has a DNR order, re-evaluating the DNR should be a routine part of informed consent for the surgeon, anesthesiologist, and parents. The writers mention the importance of compassion and listening to the parents and the need to be clear about details such as when the DNR should come back into effect if it's suspended for surgery.

If a surgeon or anesthesiologist thinks that the parents' decisions conflict with their own medical or ethical views, they should withdraw from the case, the writers say, and should consider going to the institution's ethics committee.

What the study means to you: A do-not-resuscitate order may not have the effect parents expect, and they should be sure to discuss it with the surgeon and anesthesiologist before a child has surgery.

Find out more: Another place where DNR orders may be complicated is school; this article is for school nurses: www.schoolnurse.com.

Read the article: Fallat, M.E., Deshpande, J.K., and the Section on Surgery, Section on Anesthesia and Pain Medicine, and Committee on Bioethics. "Do-Not-Resuscitate Orders for Pediatric Patients Who Require Anesthesia and Surgery." Pediatrics. December 2004, Vol. 114, No. 6, pp. 1686–1692.

Abstract online: http://pediatrics.aappublications.org