When parents agree to a do-not-attempt resuscitation (DNAR) order, they are making a life-altering decision that affects end-of-life care for their child. They are acknowledging that cardiopulmonary arrest may occur as a direct consequence of their child’s disease, but are hoping for a death with dignity.

In a clinical report to be published in the May 2018 Pediatrics, the American Academy of Pediatrics recommends that hospitals formally address the extent to which DNAR orders apply in the operating room. The clinical report, “Interpretation of Do-Not-Attempt-Resuscitation Orders for Children Requiring Anesthesia and Surgery,” to be published online April 23, updates previous recommendations published in 2004.

Surgery and anesthesia might be required, such as to provide a support device that allows the child to leave the hospital, but each procedure introduces additional risks to a patient that need to be addressed by the medical team with parents.

The clinical report calls for hospitals to require re-evaluation of DNAR orders before surgery to help the family decide whether to honor it in the operating room.