Shortly after the advent and propagation of cardiopulmonary resuscitation in the 1960s, the enthusiasm of reviving every cardiac arrest patient was hampered by the unintended consequences that patients and healthcare providers had to face. It quickly became clear that not every patient could or should be resuscitated. The weighing of the benefit of prolonging a patient’s life versus the burden of the patient suffering and postponing the inevitable had to be addressed. In 1974, the American Medical Association published the “Standards for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC)”, which stated “CPR is not indicated in certain situations, such as in cases of terminal irreversible illness where death is not unexpected” and also proposed that Do Not Resuscitate (DNR) orders be written in the chart [1]. About the same time, the modern medical ethics movement gained traction, including the upholding of the principle of patient autonomy. In 1990, the Patient Self-Determination Act was passed mandating“…that, in those healthcare institutions which receive Medicare or Medicaid funding, patients must be informed in writing upon admission of (1) their right to accept or refuse treatment, (2) their right under existing state laws regarding advance directives, and (3) any policies which the institution has regarding the withholding or withdrawing of life-sustaining treatments” [2]. Yet, the acceptance of DNR orders in the perioperative setting was slow (see Chapter 4 for a more detailed discussion on this topic). Finally in 1993, The American Society of Anesthesiologists established the “Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders or Other Directives that Limit Treatment” that recommended that DNR orders be reevaluated for the perioperative period to reflect the patient’s wishes [3]. Subsequently the American College of Surgeons released the “Statement on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room”, which also recommended the reevaluation of existing DNR orders prior to surgery [4].

The ethical challenges surrounding perioperative DNR decisions in pediatric patients can differ from those in the adult patient. In fact, some would consider pediatric patients an ethical class of their own [5]. Pediatric patients are at the beginning of their life, whereas the elderly patient has often lived a long and fulfilled life by the time end-of-life issues have to be addressed. Also, pediatric patients include multiple age groups unlike adults, ranging from neonates to adolescents. Moreover, adults with decision-making capacity can make their own decisions regarding perioperative DNR orders unlike most pediatric patients. With medical-decision making in most pediatric cases, informed permission from the parent or guardian is obtained with assent of the patient if the child is of a particular developmental age. The evaluation of a child’s ability to assent has to be done in the context of their developmental age and decision-making abilities, and not necessarily based on their chronological age alone. See Chap. 1 for a more detailed discussion on informed consent for pediatric patients, adolescents, and emancipated minors.

This chapter addresses perioperative do not resuscitate decisions in pediatric patients, the reluctance of physicians to address do not resuscitate decisions, potential obstacles to honoring perioperative do not resuscitate orders, and futile cardiopulmonary resuscitation in pediatric patients.