GuidelinesforDoNotResuscitateOrders

Cardiopulmonaryresuscitationshouldbeinitiatedintheeventofsuddenorimpending
deathunlessthereisaproperlyexecutedDoNotResuscitate(DNR)Orderora
contraindicationtoperformingCPRasoutlinedinSection3below,asdeterminedbythe
patientsattendingphysician.TheseguidelinesaddresssituationswhereDNRordersare
appropriateandhowsuchordersaretobedocumentedandexecuted.

A. CardiopulmonaryResuscitation(CPR)asaMedicalTherapy

1.WhatisCPR?
Cardiopulmonaryresuscitation,orCPR,isasetofemergencyprocedures(oftensetin
motionbycallingacode)performedonpersonsduringcardiacand/orrespiratory
arrest.Whenapatientsheartstopsbeatingeffectivelyand/orbreathingstops,CPRis
anattempttorestorefunctionsoftheheartandlungsthroughtheuseofchest
compressions,artificialrespiration,medicationsandelectricalshock(s).Thetypesof
proceduresperformedandthedurationoftheresuscitationattemptarenotstandard
butmustbeindividualizedtoeachpatientscircumstances.
Cardiopulmonaryresuscitationmaynotalwaysbeinapatientsbestinterestandmay
bewithheldwhenthereisagreementbetweenthecaregiversandthepatientor
surrogatedecisionmakerthattheexpectedbenefitsofcardiopulmonaryresuscitation
wouldnotexceedtheattendantrisksandburdens.Inaddition,acompetentpatient
hasthelegalrighttorefusemedicaltreatment,evenifitispotentiallylifesaving.
2.WhentouseCPR
Fromamedicalstandpoint,CPRisatherapydesignedforapatientwhohasa
potentiallyreversiblecardiopulmonaryarrestandforwhomthereisareasonable
possibilityoftherapeuticbenefit.

3.WhennottouseCPR

a.RefusalofCPRbycompetentadultpatients
Competentadultshavethelegallyprotectedrighttobefullyinformedaboutthe
risksandbenefitsofallalternativesfortreatmentandtoconsenttoorrefuseany
medicaltreatment,includingCPR.

b.PhysiologicallyfutileCPR
CPRshouldnotbeperformedwhenitwouldbephysiologicallyfutile;thatis,when
itwouldnotwork.CPRisnotdesignedforuseinpatientswhosemedicalcondition
makesresuscitationandmechanicalventilationineffective.Forsuchpatients,an
orderthatCPRnotbeattempted(DNRorder)maybeenteredinthemedical
record,asmorefullydiscussedinParagraphDbelow.

c.NontherapeuticCPR
CPRisalsonotdesignedforuseinpatientsforwhomCPRisnottherapeuticthat
is,thosepatientsinwhomCPRcannotreversetheongoingdyingprocessorwill
notprovidetherapeuticbenefitsthatoutweightheharmsorsubstantialburdensof
CPR(nontherapeuticCPR).Bywayofexample,cardiopulmonaryarrestisan

expectedterminaloccurrenceinpatientswithcertaindiseasesorconditionswho
arenearingtheendoftheirlifespan.Insuchcases,CPRmaytemporarilyrestore
cardiacfunctionbutthepatientsoverallconditionwillworsenand
cardiopulmonaryarrestwilloccuragainasanaturalandinevitablepartofthe
dyingprocess.ProvidingCPRinsuchcasesislikelytoharmthepatientand
contravenesthemedicalethics(includingtheprincipleofdonoharm)of
clinicians.Forsuchpatients,aDNRorderisappropriatesothatCPRwillnotbe
attempted.

B.RoleofPatientandParentsofMinorChildren
Thepatientandparents(orlegalguardian)shouldbeinvolvedinmakingdecisions
aboutCPR.Aswithotherclinicaldecisions,parentsofminorchildrenshouldbefully
informedaboutmedicalrecommendationsregardingCPRandDNR,andminorchildren
shouldparticipatetothefullestextentoftheirdevelopmentalabilitiesandemotional
state.Generally,aDNRordershouldnotbeenteredintothepatientsmedicalrecord
withoutconcurrenceoftheparents.However,aDNRordermaybeenteredbythe
patientsphysicianwithoutparentalpermissionifCPRisdeterminedtobe
physiologicallyfutileornontherapeutic,inaccordancewithParagraphsEandFbelow.
C.DocumentationofaDoNotResuscitate(DNR)order
DocumentationinthepatientsmedicalrecordofadecisionnottodoCPRmust
includebothaPhysiciansOrderandanentryintheProgressNotes.Useofthe
standardizedDNROrderFormispreferred,butisnotrequiredincaseswherethe
attendingphysicianprefersanarrativemethodofdocumentation.

DocumentationintheProgressNotesshouldincludethefollowingandbewrittenor
cosignedbytheattendingphysician:
1. Whyandhowtheinitialquestionofresuscitationstatuswasraised.
2. Decisionmakingprocesswhichhasbeenandwillbefollowed:
a. Professionalstaffinvolvement;
b. Roleofparentsandpatient;
c. Datauponwhichdecisionisbased.
3. Summaryandupdateofplanningprocessanddecision.
4. Summaryofconversationswithpatientsandparents.
Subsequentprogressnotesshoulddocumentreevaluationofthepatients
conditiononatimelybasis,continuedappropriatenessoftheDNRorder,and
familyinvolvement.

Discussion(s)regardingresuscitationstatuswiththepatientand/orfamilyarethe
responsibilityoftheattendingphysician.ThePhysiciansOrder,whetherutilizing
thestandardizedformoranarrativeformat,mustbesignedbyanattending
physicianandnurse.Whenthepatientsattendingphysicianisnotimmediately
availabletosigntheorder,thenahousestaffphysicianmaysigntheorder,after
conferringwiththeattendingphysicianoverthephonetoverifythe
appropriatenessoftheorder,anddocumentthisconversationinthechart.Under
thesecircumstances,theattendingphysicianmustphysicallysigntheformassoon
aspossibleandinanycasenolaterthan24hoursaftertheorderisenteredinto
thepatientsmedicalrecord.Inaddition,anexpirationdate,ifany,shouldbeset
forthintheorders.

Intheremainderofthispolicy,thetermParent(s)willbeusedtorefertothelegallyauthorized
decisionmaker(s)forachildandshouldbeunderstoodtorefertothelegalguardianwhenappropriate.
Whenthepatientisacompetentadult,thepatientisthelegallyauthorizeddecisionmaker.


Theprimarynurseandattendingphysician(ortheirdesignees)areresponsiblefor
ensuringthatallpertinentcaregiversareawareoftheDNROrder.Whenever
possible,medicalandnursingstafffromotherunitsorfacilitieswhowillbe
providingcare,orwhowillresumecare,shouldbeinvolvedindiscussionsabouta
DNROrdertoenableunderstandingandcontinuityofcare.
D.EntryofDNRorderincasesofdisagreementbetweenclinicalstaffandparent(s)
Inalmostallcircumstances,parentsandclinicalstaffshouldreachagreement
aboutwhetheraDNRorderisappropriateforthepatientbasedonthepatients
prognosis,therisksofharmandpotentialbenefits,ifany,thatmaybeexpectedof
CPR,andthevaluesoftheparent(s)andpatient.Nevertheless,onrareoccasions,
parentsmayrequestCPReventhoughtheclinicalteamhasconcludedthatCPRis
eitherphysiologicallyfutileornottherapeutic.Theprocessfordealingwithsuch
disagreementsdependsonthereasonCPRisconsideredinappropriate.
Whenthereisagreementamongclinicalstaffcaringforthepatient(i.e.theclinical
team)thatCPRisphysiologicallyfutile,parentsshouldbeinformedandtoldthata
DNRorderwillbewritteninthechart.Parentswhodisagreewiththeclinical
decisionnottodoCPRshouldbegivenareasonableopportunitytoobtaina
secondopinionortransferthepatientunlessthechildsconditionprecludesdoing
so.Clinicalstaffarenotrequiredtoperformphysiologicallyfutileandharmful
treatmentsonapatient.
WhenthereisagreementamongclinicalstaffcaringforthepatientthatCPRis
nontherapeuticandthatperformingCPRviolatestheirmedicalethicaldutytothe
patient,andifparentsstillwantCPRtobeperformed,theclinicalteamshould
initiateaprocessofreviewtodeterminewhetheraDNRordermaybeentered
despitethedisagreementoftheparent(s).

E. ProcessforreviewingdisagreementsaboutwhetherCPRistherapeutic

IfthepatientsclinicalteamhasconcludedthatperformingCPRonthepatient
wouldnotbetherapeutic,andiftheteamhasbeenunabletoreachagreement
withtheparentsaboutenteringaDNRorder,thenstaffand/orparentsshould
initiatethefollowingreviewprocess:

a. Theclinicalstaffshouldconfirmthatmembersofthepatientsclinicalteam
areinagreementthatCPRshouldnotbeperformedonthepatientbecauseit
isnontherapeutic.
b. Asecondopinionshouldbeobtainedfromaphysiciannotonthepatients
clinicalteamaboutwhetherCPRisnontherapeutic.
c. Ifthesecondopinionsupportstheconclusionoftheclinicalteam,amemberof
theclinicalteamshouldcontacttheEthicsOfficetoscheduleanethicsconsult.
d. Hospitalstaffwillworkactivelywiththepatientsparent(s)andothercare
providers(suchasthepatientsprimarycarephysician,schoolnurses,group
homestaff,etc.)toappreciatetheirconcernsandplanforcarewithoutCPR.
e. IftheethicsconsultsupportsentryofaDNRorderdespitetheparents
disagreement,theclinicalstaffshouldinformtheChiefofServiceandtheLegal
Office.
f. IftheServiceChiefconcurs,andifthelegalofficeconfirmsthatjudicial
involvementisnotnecessary,theparentsshouldbetoldthataDNRorderwill
beenteredintothepatientsmedicalrecord.
g. Parentsshouldbegivenareasonableopportunityandassistancetotransfer
thepatienttoanotherfacilitywillingtoacceptthepatient.

h. Ifitisnotpossibletotransferthepatient,aDNRordermaybeenteredintothe
patientsmedicalrecord.

F.MandatoryReassessmentofDNROrdersBeforeAnestheticandSurgical
Procedures

PatientswithDNRordersmaybeappropriatecandidatesforanesthesiaand
surgery,especiallyforproceduresintendedtofacilitatecareorrelievepain.The
etiologiesandoutcomesofcardiacarrestduringanesthesiaaresufficiently
differentfromthoseinnonsurgicalsettingsthatreevaluationoftheDNRorderis
alwaysnecessary.Thefactthatcardiacarrestismorelikelytobereversiblewhenit
occursduringanesthesiawilloftenmeanthatitisinthepatientsbestinterestto
havetheDNRordersuspendedduringtheintraoperativeandimmediatepost
operativeperiods.Insomecases,however,patientsortheirparentsmaydesire
limitationsontheresuscitativeproceduresusedthroughouttheperioperative
period.

Theadministrationofanesthesianecessarilyinvolvessomepracticesand
proceduresthatmightbeviewedasresuscitationinothersettings.Forexample,
routineanestheticcareusuallyrequiresplacementofanintravenouscatheter,
administrationofintravenousfluidsandmedications,andmanagementofthe
patientsairwayandrespiration.Chestcompressionsandelectricalcardioversion,
ontheotherhand,aregenerallynotintrinsictotheanestheticorsurgical
procedure.

Theanesthesiologist,inconjunctionwiththepatientsotherattendingphysicians,
isresponsiblefordiscussingtheseissueswiththepatientand/orfamily,reassessing
thepatientsDNRstatuspriortosurgery,andcommunicatingthesedecisionsto
thosewhowillbeinvolvedwiththepatientscareduringtheintraoperativeand
immediatepostoperativeperiod.

ThehospitalsstandardizedDNROrderformmaynotbethebesttoolfor
consideringanddocumentingDNRstatusduringtheperioperativeperiod.
Alternatively,agreementwiththepatientand/orfamilyononeofthefollowing
threeoptionsmaymeettheneedsofmostpatientswithDNRstatuswhorequire
anesthesiaandsurgery:

Option#1:FullResuscitation
Thepatientdesiresthatfullresuscitativemeasuresbeemployedduringsurgery
andinthePACU,regardlessoftheclinicalsituation.

Option#2:LimitedResuscitation:ProcedureSpecific
Thepatientdesiresthatfullresuscitativemeasuresbeemployed,withthe
exceptionofcertainspecificprocedures,suchaschestcompressionsorelectrical
cardioversion.Asnotedabove,however,certainproceduresareessentialto
providingtheanestheticcare(suchasairwaymanagementandintravenousfluids).
Refusaloftheseprocedureswouldnotbeconsistentwitharequestforanesthesia
andsurgery.

Option#3:LimitedResuscitation:GoalSpecific
ThepatientdesiresresuscitativeeffortsduringsurgeryandinthePACUonlyifthe
adverseclinicaleventsarebelievedtobebothtemporaryandreversible,inthe
clinicaljudgmentoftheattendinganesthesiologistsandsurgeons.Thisoption
requiresthepatientand/orsurrogatetotrustthejudgmentofthe
anesthesiologistsandothercaregiverstouseresuscitativeinterventions
judiciously,basedupontheirunderstandingofthepatientsvaluesandgoalsof
treatment.


Oneoftheoptionsoutlinedabove,oranotherifappropriate,shouldbe
documentedintheProgressNotes.TheoriginalDNRordershouldbereinstituted
atthetimethepatientleavesthecareoftheanesthesiologist(upontransferoutof
theORorPACU),unlessotherwisedocumented.

Ifthepatient/parent(s)electstohavetheDNRorderremainineffectduring
anesthesiaandsurgery,physiciansandothercaregivershavetheoptionof
decliningtoparticipateinthecase.Shouldanycaregiverdeclinetoparticipate,he
orshemustmakeareasonableefforttofindanotherwhoiswillingtotreatthe
patient.
G.Patientswhoare18orOlder

Asageneralrule,patientswhoare18yearsofageorolderareentitledtomake
decisionsontheirownbehalf.However,incertaincases,whenchildrenoverthe
ageof18arenotabletomaketheirowndecisions(areincapacitated),parents
maybeauthorizedtomakedecisionsontheirbehalf.

1. Parentsofchildrenwhoarementallyincapacitatedmayhavebeengiven
authoritybythecourttoserveasguardiansfortheirchildren.

2. Parentsmayhavebeendesignatedhealthcareagentsorproxiesintheiradult
childsadvancedirectiveafterthechildturned18,andthusareauthorizedto
makedecisionswhentheirchildisnolongercapableofdoingso.

3. Incertaincircumstances,evenabsentacourtorderoranadvancedirective,
parentsmaybetheappropriatesurrogatesfortheiradultchild(justasa
spouseorchildmaybetheappropriatesurrogateforanadultwhohasnot
completedanadvancedirective).Bywayofexample,parentsofachildwitha
chronic,degenerativeillnessmaybetheappropriatesurrogatefortheirchildin
theeventadecisionmustbereachedaboutDNRandthechildnolongerhas
decisionmakingcapacity(butdidnotcompleteanadvancedirective).Parents
mayalsobetheappropriatesurrogatesforachildover18whobecomeillor
injuredunexpectedlyandisunabletomakedecisionsonhis/herownbehalf.
Legalcounselshouldbecontactedinthesecircumstances.

H.DiscontinuationofaDNROrder

ADNRordermayberevokedbyacompetentpatientorsurrogatedecisionmaker,
unlesstheDNRorderhasbeenenteredbecauseCPRisphysiologicallyfutile,or
becauseithasbeendeterminedtobenontherapeutic,providedthereview
processsetforthinParagraphEhassupportedsuchdetermination.Anymember
oftheclinicalstafforfamilymayrequestthataDNRorderbereevaluated.
DiscontinuationoftheDNRordermustbenotedintheappropriateplaceonthe
DNROrderSheet(ordocumentedinthePhysiciansOrdersifaDNROrderSheetis
notused),andexplainedintheProgressNotes.
I.EthicalConcerns
TheHospitalEthicistandEthicsAdvisoryCommitteeareavailabletoanymemberof
thehealthcareteam,family,andpatient,foradviceaboutethicalconcerns,
includingdecisionsaboutresuscitationorotherlifesustainingtreatments.The
OfficeofEthicscanbereachedatx6920andanEthicistisalwaysavailableby
pager.

J.LegalConsiderations
Ifclinicalstaffbelievelegalconsultationisnecessaryormightprovehelpful,an
attorneywiththeHospitalsOfficeofGeneralCounselshouldbecontactedat
x6800or,ifurgent,bypager.Forexample,whenachildisinstatecustodythrough
MassachusettsDepartmentofChildrenandFamilies,anethicscommittee
consultationandcourtreviewofdecisionstolimitlifesustainingtreatmentsis
legallyrequired.Hospitalcounselmightalsobeconsultedwhenguardiansor
attorneysareinvolvedonbehalfofthechildand/orparent(s),orwhenthereare
concernsaboutconflict,consentordocumentation.
K.DNRordersforEmergencyMedicalTechnicians(EMTs)
TheMassachusettsDepartmentofPublicHealthsOfficeofEmergencyMedical
ServiceshasdevelopedtheCOMFORTCAREDNRVerificationprogramtoprovidea
mechanismforEMTsandFirstResponderstoidentifypatientswhohaveDNR
ordersandtoinitiateaprotocolfocuseduponcomfortandpalliativecarerather
thanautomaticemergencyCPR.ThepatientsDNRstatusisindicatedbya
standardizedstateformthatmustbeimmediatelyavailabletoEMSpersonnel
and/oranorangebraceletonthepatientsarm.Theattendingphysicianis
responsiblefordeterminingwhetherapatientneedsaDNRverificationorderand
forcompletingtheCC/DNRFormandBracelet,providingacopyfortheparent(s)
andplacingacopyoftheCC/DNRforminthepatientsmedicalrecord.The
appropriateformsandinformationalbrochuresareavailableontheCriticalCare
units,ormaybeobtainedfromtheMICUOffice(x7327),theOfficeofEthics
(x6920),theOfficeofGeneralCounsel(x6800),oronlineat
http://www.mass.gov/eohhs/provider/guidelinesresources/clinicaltreatment/comfortcare/
SincetheCC/DNRprogramappliesonlytoEMTsandFirstResponders,the
attendingphysicianmayalsowanttoprovideastatementonthephysicians
letterheadand/oracopyoftheChildrensHospitalDNRformtoprovidenon
bindingguidancetootherswhomayneedinformationregardingthepatients
resuscitationstatus,suchasvisitingnursesoremergencyphysiciansatChildrens
Hospitalorotherinstitutions.Asageneralrule,validCC/DNRFormsorBracelets
willbehonoredbythemedicalandnursingstaffofChildrensHospitalEmergency
DepartmentandintheChildrensHospitalAmbulatoryClinics.

ApprovedMSEC9/98
Revised7/99
Revised/2009
ApprovedMSEC1/2012