Center for the Study of Ethics in the Professions at IIT

818 HARRISON AVENUE
BOSTON, MASSACHUSETTS 0211B
GUIDELINES DO NOT RESUSCITATE ORDERS

There are circumstances in which an order not to resuscitate may properly be issued in connection with the care of a patient. In light of recent court cases, especially In the Matter of Shirley Dinnerstein, Department of Health and Hospitals wishes to promulgate formal guidelines with respect to Do Not Resuscitate (DNR) orders.

These guidelines apply only in the case of irreversibly terminally ill patients. "Irreversibly, terminally ill" is not further defined by law, however, the thrust of this phrase is that the law does not require a prolongation of the act of dying simply because the current state of medical technology has put measures in the physician's hands that permit the postponement of the time of death. A significant factor to be taken into account in determining whether the patient is "irreversibly terminally ill" is whether there is any treatment available that offers the patient a reasonable expectation of even a temporary return towards a normal, functioning, integrated, cognitive experience. If the physician has any questions about the meaning of the phrase "irreversibly, terminally ill," he/she should consult with another physician.

1. In the case of a competent, irreversibly, terminally ill patient, a DNR order may be written upon the patient's informed consent to issue an order not to resuscitate. If the physician has any doubts whether a patient is competent or not, a consultation must be obtained with a psychiatrist.
   

2. If the patient is incompetent, or a minor and irreversibly, terminally ill, a DNR order may be written if the attending physician determines in light of the patient's history and condition and the wishes of the patient's immediate family that it would be medically inappropriate to institute efforts at resuscitation. Where possible, immediate family should be limited to spouse, children, and parents. Consent of the spouse alone should be sufficient, but if the spouse is deceased, the consent should be given by all children who have reached majority or, if there are no children, by both parents. The limitation to immediate fan-Lily members is not intended to prohibit a physician from contacting other family members who the physician may feel have a close relationship with the patient and who may desire to be involved in the process.
   
   No DNR order should be issued and an AOD should be contacted in the following circumstances:

1. No family is available,

2. Only fan-Lily members other than a spouse, child, or parents are available,

3. The physician wishes to issue a DNR order and faces opposition from the patient's family,

4. There is dissention among the patient's family, or

5. A competent patient has requested resuscitation and then becomes incompetent.
   
   

   3. In the case where a DNR order is decided upon, the physician must record the order clearly and promptly in the patient's chart. The following must be included in the progress notes:

   1. A summary of staff discussion and decision regarding the patient's condition,

   2. Documentation of the patient's competence or incompetence

   3. a summary of disclosures made to the patient or family

   1. a summary of the patient's or family's response,

   2. a statement of the circumstances of the consent by the patient,

   3. signature or cosignature of Attending Staff on all DNIR orders,

   4. In the case of a court order, a copy of the order should be put in the chart.
      
      The recording requirement, whether met by "documentation," "summaries" or "statements," is fully intended to be a flexible concept requiring the establishment of a record of the events, incidents, discussions, professional decisions and their basis, which have led to the order, in a manner which is sensitive to patients and their families.
      
      The decision not to resuscitate must be conveyed to all appropriate medical, nursing and other staff. The responsible physician should continually re-evaluate the patient's competency and consent. This must clearly be noted in the chart and, if appropriate, the DNR order revoked.

   4. Any physician may contact hospital counsel directly in issues regarding DNR orders. In following these guidelines, however, all physicians are urged to contact the AOD before speaking with the lawyers for the Department. The role -of the AOD in this process is to assist in gathering information necessary to make a full and complete presentation of the particular issue to hospital counsel, or assist in gathering information which my obviate the need to contact hospital counsel, and to provide administrative expertise which may have been gained in dealing with similar issues in the past.