OBJECTIVE: To evaluate outcomes of patients who undergo surgery with a do-not-resuscitate (DNR) order. DESIGN: Retrospective cohort study. SETTING: More than 120 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2008. PATIENTS: There were 4128 adult DNR patients and 4128 age-matched and procedure-matched non-DNR patients. MAIN OUTCOME MEASURES: Outcomes were occurrence of 1 or more postoperative complications, reoperation, death within 30 days of surgery, total time in the operating room, and length of stay. The χ(2) test was used for categorical variables and t and Wilcoxon tests were used for continuous variables. Multivariate logistic regression was done to determine independent risk factors associated with mortality in DNR patients. RESULTS: Most DNR patients were white (81.5%), female (58.2%), and elderly (mean age, 79 years). Compared with non-DNR patients, DNR patients experienced longer length of stay (36% increase; P < .001) and higher complication (26.4% vs 31%; P < .001) and mortality (8.4% vs 23.1%; P < .001) rates. Nearly 63% of DNR patients underwent nonemergent procedures; they sustained a 16.6% mortality rate. After risk adjustment, DNR status remained an independent predictor of mortality (odds ratio, 2.2; 95% confidence interval, 1.8-2.8). American Society of Anesthesiologists class 3 to 5, age older than 65 years, and preoperative sepsis were among independent risk factors associated with mortality in DNR patients. CONCLUSIONS: Surgical patients with DNR orders have significant comorbidities; many sustain postoperative complications, and nearly 1 in 4 die within 30 days of surgery. Do-not-resuscitate status appears to be an independent risk factor for poor surgical outcome.