Ethical issues: DNR, capacity, surrogates, refusal

Why examiners ask this

Ethical conflicts reach the anesthesiologist at the worst time: the morning of surgery, with a DNR order nobody discussed, a confused patient whose daughter wants everything done, or a Jehovah's Witness who will refuse blood during a bleeding case. The station tests whether I can name the principle at stake, gather the facts that decide it, lay out the real options, find out what the patient values, and reach a plan everyone can live with. The grader is listening for a process, not a verdict: the outline asks me to obtain relevant information, clarify options, determine preferences, negotiate differences and arrive at a decision with patients, families and other stakeholders.¹ The ABA sample is a patient with metastatic melanoma and a month-old DNR order who needs an urgent appendectomy with intubation, and the task is the DNR conversation alone, not general consent.²

The 60-second answer

Decision points and the "why"

• Identify the issue — name the conflict and the principle: autonomy against beneficence in a refusal, non-maleficence in potentially inappropriate treatment, distributive justice in allocation of resources. The outline's example areas include surrogates, capacity, informed refusal, confidentiality, end-of-life care and conflicts of interest.¹
• Gather information — capacity is decision-specific: can the patient understand, appreciate, reason and express a choice? If not, who is the surrogate under state law, and is there an advance directive? Facts decide ethics stations.
• Clarify the options — for a DNR patient, the ASA's required reconsideration offers three paths: full resuscitation, procedure-directed limits (for example, no chest compressions but vasopressors allowed), or goal-directed limits where I use judgment toward the patient's stated goals. Options turn a standoff into a choice.
• Determine preferences — I ask about values, not procedures: "What matters most to you if something goes wrong?" Surrogates are asked what the patient would want, not what they want.
• Negotiate — where preferences and my obligations conflict, I look for common ground: cell salvage for a Witness who accepts it, a time-limited trial of ventilation, a second opinion. Beneficence is served by finding what the patient will accept.
• Decide and document — a clear plan, shared with surgeon, nursing and the chart. An agreement that lives only in the room protects no one.

The complication they will inject

The daughter of an elderly patient with moderate dementia says, "Mom signed a DNR years ago, but I'm her power of attorney and I want everything done." I do not take sides immediately. I acknowledge her fear, then gather information: does the patient have capacity for this decision today, and what did she say about her wishes when the DNR was written? I explain that a surrogate's role is substituted judgment: what her mother would choose. If the patient can participate, I talk with her directly. If the conflict persists, I say that I will not proceed electively over an unresolved dispute and that I will involve the surgeon, the primary team and the ethics consultation service. In an emergency I act on the best available evidence of the patient's wishes. A variant is the adult Witness who refuses all blood; I confirm the refusal privately, without family pressure, document the specific products accepted, and honor it.

Pitfalls that cost points

• Announcing a verdict before gathering information.
• Treating a DNR order as automatically suspended in the operating room.
• Asking the surrogate what they want rather than what the patient would want.
• Lecturing on principles instead of applying them to this patient.
• Forgetting to say who else I will involve: surgeon, ethics committee, risk management, or the court for a minor.

Rapid-why

Q: Who decides capacity? A: The treating physician, for this decision at this time; a psychiatry consult helps but is not required.

Q: Can parents refuse blood for a child? A: For a life-threatening emergency I transfuse and seek a court order or follow institutional policy; for elective cases I plan ahead with the family and the legal team.

Q: How do I open the DNR conversation? A: "Your order says no resuscitation. Anesthesia itself sometimes requires treatments that look like resuscitation, so I want to know what you'd want here."

Q: What if the patient changes their mind? A: A patient with capacity can revoke or modify a directive at any time; I document the change and tell the team.

Numbers to know

Links

• Ethical principles reference (ASA guidelines) (coming), Treatment options and informed consent, Communication with other professionals and conflict, Massive hemorrhage and transfusion, Brain death and the organ donor (coming)
• ASA Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders; ASA Guidelines for the Ethical Practice of Anesthesiology