To provide guidelines for the implementation of orders not to attempt resuscitation.
- Do Not Attempt Resuscitation (DNAR): In the event of an acute cardiac or respiratory arrest, no cardiopulmonary resuscitative measures will be initiated. Note that it is always appropriate to continue measures to maintain patient comfort.
- Colorado CPR Directive: A form authorized by Colorado State Statute that allows a person over the age of 18 or the parents of a minor to state their wishes to forego the use of resuscitative measures at the time of a cardio-respiratory arrest.
- Ethics Consultation Team: An on-call group of trained ethics consultants who are able to provide a values-based discussion of alternative approaches to treatment that will facilitate medical decisions by patients, families and health care team members.
- The DNAR Order Form: A printed order form that is signed by the attending physician and displayed prominently in the chart to officially state that a Do Not Attempt Resuscitation Order is in place.
Statement of Ethical Principles
- Beneficence: As in any medical intervention or treatment, the use of life prolonging therapies at the time of cardiac or respiratory arrest must have as the goal the comprehensive benefit of the patient. This goal is usually clear in the case of a patient who has been in good health and suddenly has failure of life sustaining organ systems. The patient who has complex medical or surgical problems may have goals of care that are not served by resuscitation at the time of arrest. This guideline addresses the process to determine in specific patients whether resuscitative efforts should be withheld.
- Avoiding Harm: Even though invasive medical procedures cause harm to patients, using them is justified by the net balance of providing benefits over burdens. The process of decision making regarding resuscitation in the event of cardiac or respiratory arrest must involve an assessment of the proportionality between comprehensive benefit and harm to the patient.
- Autonomy: A patient who has decision making capacity should be included in the process of considering a do not attempt resuscitation order. In pediatrics the parents or guardians of the patient usually assume primary decision making authority, and their informed permission is always necessary in the non-emergent decision to issue a DNAR order.
- Continuity of Care: Once a decision for DNAR is made it should be communicated carefully and completely to all involved care givers. The primary care physician (PCP) should be included in the DNAR process whenever possible. The use of the Colorado CPR Directive is a legally recognized method of extending the decision not to resuscitate to care situations in the outpatient setting. The CPR Directive is a valid DNAR order and if available will be followed by first responders. Patients, parents and legal guardians who have made an informed decision to have a DNAR order in the hospital should be given the opportunity to have a Colorado CPR Directive at the time of discharge.
Consideration of DNAR Decision
Prior to the implementation of a DNAR order:
- A comprehensive evaluation of the patient’s medical condition should be done by the attending physician. Consultation should be used, when appropriate, to determine that the diagnosis and prognosis are as accurate as possible.
- The patient’s condition and prognosis should be discussed with those members of the health care team who are actively involved in the patient’s care and their opinions should be actively solicited. If there is disagreement about the goals of care and the proposed DNAR order consideration should be given to a care conference with the Ethics Consultation Team.
- The possibility of a DNAR order should be discussed with any patient who has the capacity to understand the implications of such an order, and with the parents/legal guardians whose informed permission is required for patients without decisional capacity. Additional discussion with individuals important to the family may be important as a source of support in this difficult matter. The help of the Ethics Consultation Team for the hospital may be requested at any time.
Implementation of DNAR Orders
Once the decision to implement a DNAR order has been made:
- Only the attending physician will document and sign the DNAR Order Form that states DO NOT ATTEMPT RESUSCITATION. The only exception to this can occur if a patient has a valid Colorado CPR Directive in place.
- The attending physician will document in the progress notes that the steps discussed under Consideration of DNAR Decisions have taken place, and note the individuals who were involved in the decision.
- The attending physician will notify the bedside nurse and/or charge nurse of the DNAR order. It is the responsibility of these nurses to convey the orders to subsequent nursing personnel. Only properly written and communicated DNAR orders will allow hospital personnel to refrain from resuscitative efforts.
- If the patient is transferred to another service or level of care in the hospital, or to the care of a different attending physician, the DNAR order must be rewritten by the new attending physician and conveyed to the appropriate personnel within 24 hours.
- If a decision to alter the DNAR status on the patient is reached at any time during the hospital stay a new order must be written by the attending physician. This order must be conveyed to the appropriate personnel immediately. The DNAR order may be canceled, after appropriate review by all involved parties, by drawing an X through the DNAR order form and having the attending physician sign on the bottom of the form.
- DNAR orders should be reviewed periodically, usually weekly.
- Patients with completed CPR Directives signed by an attending physician should have those Directives honored on admission, and the DNAR order may be written by a senior resident or fellow, after discussion with the patient or parents/guardians and inpatient attending physician. Attending physicians must sign these orders within 24 hours of admission.
DNAR Order at the Time of Medical or Surgical Intervention
- When a patient on DNAR status requires medical or surgical intervention, physicians involved in that patient’s care including the PCP should engage in a discussion with the patient or surrogate decision makers regarding the handling of the DNAR order. The administration of anesthesia necessarily involves some practices and procedures that might be viewed as “resuscitation” in other settings. Discussion should include information about the likelihood of requiring resuscitative measures, a description of these measures, the chances of success, and possible outcomes with and without resuscitation.
- Salient features of this discussion must be documented in the patient’s progress notes. The patient/surrogate decision makers should have a clear understanding about which procedures are 1.) essential to the success of the anesthesia and the proposed procedure, and 2.) which procedures are not essential and may be refused. All the staff involved should be aware of the overall plan of care, including the intra-operative and post-operative periods.
- The patient/surrogate decision makers may allow the anesthesiologist and surgical team to use clinical judgment in determining which resuscitation procedures are appropriate in the context of the situation and the goals of care for the patient. For example, full resuscitation procedures may be appropriate to manage adverse clinical events that are believed to be quickly and easily reversible, whereas treatment for conditions that are likely to result in permanent sequelae such as neurologic impairment or dependence on life-sustaining technology may not be indicated.
- When disagreements arise about further medical or surgical intervention in patients with a DNAR order in place, an Ethics Consultation should be considered.
Identification of Patient on DNAR Status
- “Do Not Attempt Resuscitation” will be noted on the kardex and on the first page of the chart.
- The bedside drug dosage “Cor Sheet” will be folded in half and on the inside clearly marked “Do Not Attempt Resuscitation."
- Patients with a DNAR order in place will be identified when they are moved to different locations in the hospital for any reason.
Discharge of Patient with DNAR Order
- Patients being discharged who have a DNAR order in place in the hospital will have a discussion with the health care team regarding the appropriateness of having a Colorado CPR Directive at home. This Directive is the only DNAR form recognized by first responders in Colorado. It may be obtained from the nursing supervisor, the Ethics Consult Team, the office of Risk Management, or the nursing supervisor on duty.