To Resuscitate or Not?

 What’s Your Policy?

by Teresa D. Johnson

 

What is your adult day center’s protocol when a participant does not want to be resuscitated?  Is that policy written and has a discussion of it been documented with every client and his or her family at enrollment?  On what basis and laws was that policy established?  If you are not confident of positive answers for all these questions, your center is probably operating at the risk of multiple lawsuits in the event of an emergency with a person who does not want to be resuscitated!

 

Every state has varying laws on ethical issues such as prolonging life, advance directives, etc.  In an effort to clarify some issues related to do not resuscitate orders (DNRs), these findings from recent research are intended to present some talking points to help adult day centers establish written policies.  (All information presented in this article is based on findings from laws, protocols, etc. in North Carolina.  It is not considered typical or comprehensive of other states’ laws.  Please consult your state Attorney General and medical society to determine appropriate legal policies for your state.)

 

What is a DNR order?  A DNR order allows a patient or patient’s representative to refuse attempts at CPR (cardiopulmonary resuscitation) when the patient has stopped breathing and/or the patient’s heart has stopped beating.  The DNR order, written by the physician on a special form, instructs health care providers to withhold CPR.

 

What are the patient’s rights in obtaining a DNR order?  The patient has the right to control his or her own medical care, including whether or not to have a DNR order.  The patient may cancel a DNR order at any time.  The order must be reauthorized by the physician at least once a year.

 

Who is involved in completing a DNR order?  Both the physician and the patient (or the patient’s representative) must agree that a DNR order is appropriate in order for the physician to write a DNR order.  A DNR order must be signed by a physician.

 

Is a DNR order the same thing as a living will, health care power of attorney or other advance directive?  No.  Advance directives such as living wills and health care powers of attorney are directions written by an individual about his or her health care wishes.  A DNR order is an order written by the patient’s physician.  A DNR order may be based on an advance directive, if the patient has written one.  However, a patient who has not written an advance directive may still have a DNR order.

 

What is a valid DNR order?  North Carolina law recognizes two separate ways in which a DNR order may be legally written:  the Statutory Procedure and the Common Law Procedure.  The special yellow form must be completed with the patient’s name, the physician's name, address, telephone number and the effective and expiration dates.  The physician must sign the order and it must be notarized.  Additional forms may be created by completing additional approved DNR forms but photo copies are not valid.

 

What care should EMS or other care providers offer to the patient with a DNR order?  A DNR order allows EMS and other providers to withhold CPR when the patient’s condition indicates that breathing or heartbeats have stopped.  This does not mean that all care stops.  A DNR order applies only to CPR.  The physician and other health care providers should continue to provide all other appropriate care. When EMS is called because a patient’s condition has worsened, providers offer "comfort care" to make the patient as comfortable as possible.

 

What is the liability of a person who withholds CPR in response to a DNR order and then the family changes their mind and presses charges because CPR was not administered?  It is the opinion of the North Carolina Attorney General that they will not be held liable for withholding CPR for several reasons:

¨ The NC General Assembly has unequivocally stated that a patient "has the fundamental right to control the decisions relating to the rendering of his own medical care, including the decision to have extraordinary means withheld or withdrawn in instances of a terminal condition."

¨ Article 3 of Chapter 32A and Article 23 of Chapter 90 expressly state that the procedures contained therein for the exercise of this right are nonexclusive.

¨ Persons who perform CPR after a valid DNR order is presented may be at more risk of being charged with committing battery than by complying with the patient’s wishes and following the doctor’s order.

 

What should the patient do with the DNR order?  Always keep the valid DNR order, completed by a physician on the special yellow form, posted or placed in a prominent location and easily accessible.  Persons with DNR orders should present them upon arrival of medical professionals to provide treatment and upon enrollment in any health care facility, e.g. hospitals, long term care facilities, adult day centers.

 

What is the responsibility of an adult day center in regard to DNR orders?  It is critical that adult day centers learn the laws for their states.  A written protocol should be established and reviewed carefully with all staff.  The policy should be discussed with all persons enrolling who have DNRs and documentation should be made regarding understanding of the policy.  A valid copy of the order must be maintained at the center (or on the participant) at all times by the participant or his/her family in order for the center to be able to honor it.  ¥

 

Reprinted from The Information Source for Adult Day Centers®, March 1999