Ethical issues: DNR, capacity, surrogates, refusal
Stem
Mrs. Novak, an 84-year-old woman, 58 kg, with moderate dementia, fell at her care home and is scheduled tomorrow for hemiarthroplasty of a displaced hip fracture. Her chart carries a do-not-resuscitate order she signed four years ago. Her daughter, who holds health care power of attorney, is waiting in the family consultation room. Your task: discuss what the DNR order means for her mother's anesthetic and surgery. Do not obtain general anesthetic consent.
Question
The nurse said you need to talk about Mom's DNR. Does that mean you won't help her if something goes wrong during surgery?
Ideal answer
Headline"No, it doesn't mean we won't help her. Surgery means we decide together what her DNR order means in the operating room, based on what she would choose."
- Identify and open. "I'm Dr. Reyes, the anesthesiologist caring for your mother tomorrow. Can I confirm you're her daughter and her health care power of attorney? I'm glad you asked, because that's exactly why I'm here."
- Name the issue. "Some of what I do in every anesthetic, like helping her breathe with a tube or giving medicines to support her blood pressure, looks a lot like resuscitation. So before tomorrow I want to understand her wishes."
- Gather information and preferences. "What did she say when she signed the order? What mattered most to her? How is she today: could she take part in this conversation herself?"
- Clarify the three options. "We can suspend the order during surgery and treat everything fully. We can keep specific limits, for example no chest compressions but medicines allowed. Or we agree on her goals and I use my judgment to honor them. I'm asking what she would choose, not what you would want."
- Decide and document. "Whatever we decide, I'll write it in her chart and tell the surgeon and the nurses myself."
Breaking down the answer
- The grader scores a process, not a verdict — obtain information, clarify options, determine preferences, negotiate differences, arrive at a decision with patients, families and stakeholders.1 ABA sample: metastatic melanoma, a month-old DNR, urgent appendectomy with intubation; the DNR conversation alone, not general consent.2
- Identify the issue without lecturing — autonomy against beneficence in a refusal, non-maleficence in potentially inappropriate treatment, distributive justice in allocation. Six principles; example areas include surrogates, capacity, informed refusal, confidentiality, end-of-life care and conflicts of interest.1
- Gather information — capacity is decision-specific: can she understand, appreciate, reason and express a choice? If not, who is the surrogate under state law; is there an advance directive?
- Clarify the options — the ASA's required reconsideration offers full resuscitation, procedure-directed or goal-directed limits.
- Preferences are the patient's — values, not procedures; the surrogate uses substituted judgment.
- Negotiate, decide, document — common ground: cell salvage for a Witness who accepts it, a time-limited trial of ventilation, a second opinion. The plan goes to surgeon, nursing and the chart; an agreement that lives only in the room protects no one.
Follow-up question
The daughter's voice tightens: "Mom signed that years ago. I can't lose her. I'm her power of attorney and I want everything done, whatever the paper says." How do you respond?
Follow-up answer
HeadlineA surrogate whose fear pulls against her mother's documented wishes; I acknowledge her and do not take sides immediately.
"This is incredibly hard, and it's clear how much you love her." Does her mother have capacity for this decision today, and what did she say when she signed? A surrogate chooses what her mother would choose; if Mrs. Novak can participate, I talk with her directly. If the conflict persists, I will not proceed with a non-emergent case over an unresolved dispute: surgeon, primary team and ethics consultation today, because delaying her hip repair also harms her. In an emergency, I act on the best available evidence of her wishes; then everyone together after ethics.
Pitfalls that cost points
- Dismissing the order because it is four years old; its age doesn't void it — I confirm it still reflects what she would want.
- Treating a DNR order as automatically suspended in the operating room.
- Asking the surrogate what they want rather than what the patient would want.
- Forgetting who else I will involve: surgeon, ethics committee, risk management, or the court for a minor.
Rapid-fire
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 handle an adult Jehovah's Witness who refuses all blood? A: I confirm the refusal privately, without family pressure, document the specific products and techniques accepted, and honor it.
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
| Item | Value |
|---|---|
| Station time | 8 min, 4-min read, warning at 6 min3 |
| Principles in the ABA outline | 6: autonomy, beneficence, non-maleficence, accountability, fidelity, justice1 |
| Process steps | Identify, then 5: gather, clarify options, preferences, negotiate, decide1 |
| Capacity elements | 4: understand, appreciate, reason, express a choice |
| DNR options in the OR | 3: full, procedure-directed, goal-directed |
Links
- Ethical principles reference (ASA guidelines), Treatment options and informed consent, Communication with other professionals and conflict, Massive hemorrhage and transfusion, Brain death and the organ donor
- ASA Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders; ASA Guidelines for the Ethical Practice of Anesthesiology
Sources
- 1.APPLIED Examination OSCE Content Outline · ABA · theaba.org
- 2.OSCE Example Scenarios · ABA, 2023 · theaba.org
- 3.What to Expect for Your APPLIED Exam (APPLIED Exam Manual) · ABA, 2026 · theaba.orgRevised July 2026.
Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.