Do Not Resuscitate Policy and Procedure
August 2001 Review Dates:
The Medical Executive Committee
DNR Task Force Revision Dates:
To describe Cleveland Clinic's policy and procedure for initiating and following a Do Not Resuscitate (DNR Do Not Resuscitate) order.
“Do Not Resuscitate” (DNR) is a medical order to provide no resuscitation to individuals for whom resuscitation is not warranted. A Licensed Independent Practitioner LIP) documents a DNR order on the Cleveland Clinic End of Life Decision-Making form.
It is the responsibility of the patient’s primary physician to give the DNR order. The primary physician is generally the first physician listed on the patient’s data card. Primary physicians may delegate the authority to record a DNR order in the medical chart to physician residents or other appropriate LIP.
There are three specific types of DNR orders that can be initiated:
DNR Comfort Care (DNR CC) – (This is a State of Ohio Approved Portable DNR order.)
DNR Comfort Care Arrest (DNR CC Arrest) - (This is a State of Ohio Approved Portable DNR order)
DNR Specified - (Cleveland Clinic order - not portable outside of Cleveland Clinic Hospital)
Prior to any inpatient or outpatient invasive procedure for which Cleveland Clinic policy requires informed consent, any existing DNR order should, when possible, be reviewed with the patient or the patient’s surrogate decision maker. As a result of this review, the status of the DNR order during the perioperative period should be affirmed, clarified, or modified based on the preferences of the patient or surrogate.
DNR Comfort Care
“DNR Comfort Care” orders activate the DNR Protocol at the time the order is given. DNR Comfort Care means that resuscitative therapies will not be administered prior to or during a cardiac or respiratory arrest. Comfort care includes therapies and activities that promote the patient’s comfort such as, but not limited to, pain medication, oxygen, IV fluids for hydration, positioning, etc. This order is generally regarded as appropriate for patients who have terminal illness, short life expectancy, little chance of surviving CPR, and a desire to let nature take its course in the face of an impending arrest. DNR Comfort Care orders can be made portable and be given effect outside the Cleveland Clinic if the procedures set forth below are followed (see Ohio Portability Rules).
DNR Comfort Care-Arrest
“DNR Comfort Care-Arrest” orders activate the DNR protocol at the time of a cardiac or respiratory arrest. Resuscitative therapies will be administered before an arrest occurs but not during an arrest. A cardiac arrest occurs when there is an absence of a palpable pulse and a respiratory arrest occurs when no spontaneous respiration or agonal breathing is present. DNR Comfort Care-Arrest orders can be made portable and be given effect outside the Cleveland Clinic if the procedures set forth below are followed (see Ohio Portability Rules).
NOTE: The term “DNR” when “ordered” in the medical chart without additional wording shall be considered a “DNR Comfort Care-Arrest” order.
All other DNR orders are “DNR Specified” orders. DNR Specified orders modify the DNR protocol in some respect, either in treatment modalities or in the timing of the protocol activation. DNR Specified orders cannot be made portable and given effect outside the Cleveland Clinic.
Responsibility and Oversight
The Medical Staff is responsible for implementation of the policy.
The Ethics Committee and the Department of Bioethics is responsible for oversight and education of the DNR Policy.
Patient Consent to a DNR Order
DNR is a medical order to be given only by authorized LIP's. DNR orders generally should be given with the informed consent of the patient or the patient’s surrogate decision-maker. Ideally, the physician should discuss the DNR option with the patient while the patient is mentally competent.
However, DNR orders are often considered for patients with whom this discussion has not occurred or cannot occur due to current condition (comatose, unconscious, etc.) or who otherwise lack decisional capacity. If the patient lacks decisional capacity, the DNR option should be discussed with a surrogate. A patient may designate a surrogate as the Attorney-in-Fact in a Durable Power of Attorney for Health Care document. A surrogate may also be identified as the first available person(s) from the following list and in the following order: legal guardian, spouse, majority of adult children, parents, majority of adult siblings, or other nearest adult relative.
In all cases, the primary physician will discuss the DNR option with the patient if possible and the surrogate(s) if appropriate. There is not obligation to offer or initiate CPR if resuscitation would be futile, i.e., if resuscitation would not achieve its physiological objective, would offer no benefit to the patient or would violate reasonable medical standards.
DNR decisions for inpatients will be communicated among those caring for the patient.
A DNR order never results in the abandonment of a patient, and steps should be taken to assure that abandonment is not perceived.
Recording the DNR Order in the Medical Record
The “DNR Comfort Care”, “DNR Comfort Care-Arrest”, and “DNR Specified” order will be recorded on the End of Life Decision-Making form. The order should include the date, time, rationale for the DNR order, the names of the patient and/or family members involved in the decision, and a statement that the patient and/or surrogate was fully informed about and consented to the DNR order.
Cleveland Clinic DNR Identification Bracelet
Absent compelling medical circumstances, Cleveland Clinic inpatients that have a DNR order in the medical record will be provided a Cleveland Clinic DNR identification bracelet. This identification bracelet is intended to facilitate communication and direct care to comply with DNR orders, especially in emergencies. Cleveland Clinic DNR identification bracelets will be uniform in color and style. The bracelet will contain the inpatient’s name, Cleveland Clinic patient history number, and the type of DNR order in effect. Patients wearing state-approved DNR bracelet (see Ohio Portability Rules) will also be given a Cleveland Clinic DNR identification bracelet during their hospitalization.
Cleveland Clinic DNR Information Pamphlet
An informational pamphlet that explains Cleveland Clinic policy and the Ohio law regarding DNR orders is available to all Cleveland Clinic inpatients and outpatients. The pamphlet includes explanations of the types of DNR orders at the Cleveland Clinic, the use of the Cleveland Clinic DNR bracelet, the status of DNR during invasive procedures, the manner in which DNR orders may be revoked, and Ohio’s DNR portability regulations. The pamphlet encourages patients and family members to ask their physicians any question they may have about DNR.
Invasive Procedures and Anesthesia Care-Reassessment of DNR Orders
The administration of anesthesia necessarily involves some practices and procedures that might be viewed as resuscitation in other settings. Prior to any inpatient or outpatient invasive procedure for which Cleveland Clinic policy requires informed consent, any existing DNR order will, when possible, be reviewed with the patient or the patient’s surrogate decision maker. As a result of this review, the status of the DNR order during the perioperative period should be affirmed, clarified, or modified based on the preferences of the patient or surrogate. Clarifications or modifications should be documented on the Reassessment of Do Not Resuscitate Order form and include a notation indicating if or when the original DNR order should be reinstated. The Cleveland Clinic DNR identification bracelet should not be removed during the perioperative period, even if a DNR order has been only temporarily modified or suspended. Concurrence on these issues by the primary physician, the surgeon and the anesthesiologist is desirable.
Modification or Revocation of DNR Orders
DNR orders will be modified or revoked after a discussion between the primary physician and the patient, if possible, or the surrogate(s) if appropriate and with the consent of the patient and/or surrogate. DNR orders will be reviewed as often as the patient’s condition warrants and modifications or revocation should be documented in the medical record as a physician order.
Modified DNR Orders
When a DNR order is changed from one type to another, the physician or designee will print CANCEL across the current End of Life Decision-Making Form, sign and date the form. The physician will complete a new End of Life Decision-Making Form to reflect the new DNR order. Nursing staff will remove and replace the DNR identification bracelet reflecting the new DNR status.
Revoked DNR Orders
When a DNR order is revoked, the physician or designee prints CANCEL across the current End of Life Decision-Making Form, signs and dates the form. The attending physician will also write a notation on a physician order sheet stating, “DNR cancelled” with date and time. Nursing staff will remove the DNR identification bracelet from the patient and will report to other nursing staff that the DNR order is cancelled.
Conflicts Between DNR Orders and Advance Directives
In the event of a conflict between one of the three types of DNR orders and an Advance Directive which has become effective because a person is unable to communicate and is terminally ill or permanently unconscious, the instructions from the document (or person named as Attorney-in-Fact) ranked higher in the following list shall prevail:
Living Will of a person who is in terminal condition or a permanent unconscious state.
Durable Power of Attorney for Health Care, or an Attorney-in-Fact acting in accordance therewith, of a person who is in a terminal condition or a permanent unconscious state.
Cleveland Clinic Hospital Admissions, Transfers and Discharges- Ohio DNR Portability
“DNR Comfort Care” and “DNR Comfort Care-Arrest” orders may be made portable; meaning they would be honored statewide by EMS and other emergency care workers outside the Cleveland Clinic. In order to make DNR Orders portable, the orders need to be written on the State-Approved forms that include the State-Approved DNR Comfort Care Logo.
NOTE: DNR Specified orders cannot be made portable. A portable DNR order is either DNR Comfort Care or DNR Comfort Care-Arrest.
Admissions to Cleveland Clinic
State-Approved DNR identification forms, bracelets, and necklaces of any patients admitted to the Cleveland Clinic Hospital will be honored (see the Ohio Portability Rules). The DNR status of these patients will be reassessed upon admission, and the patients will be given a Cleveland Clinic DNR identification bracelet.
Transfers from Cleveland Clinic to other Facilities
The Cleveland Clinic will notify the receiving facility and the transport team of the State-Approved DNR status of any patient that the Cleveland Clinic transfers to that facility.
Converting DNR Specified Orders to Portable DNR Orders upon Patient Discharge
Consideration to convert the Cleveland Clinic DNR Specified Order to the State-Approved DNR Order will be made for patients with a Cleveland Clinic DNR Order who is being discharged from Cleveland Clinic.
The processes for making a DNR order portable include:
Physician will confirm with patient/family if Portable DNR is requested upon discharge.
If patient requests Portable DNR, then Physician will complete Ohio DNR form indicating DNR CC or DNR CC Arrest.
Patient will be provided with one of the following for identification of DNR status:
DNR identification form with the state-approved DNR Comfort Care Logo
A transparent hospital-type bracelet with an insert that has a State-Approved DNR Comfort Care Logo
A wallet card with the State-Approved Comfort Care Logo
A prescription for either a bracelet or necklace manufactured pursuant to the specifications of the Ohio Department of Health.
Consultations and Advice
The Department of Bioethics, the Office of General Counsel, and the Ethics Committee are available for consultations regarding the applicability of this policy to specific patients.
Resuscitation is a medical procedure that seeks to restore cardiac and/or respiratory functions to individuals who have sustained a cardiac and/or respiratory arrest. Cardiopulmonary resuscitation (CPR) is the common term used to refer to resuscitation. However, the options available to treat very sick patients are broader than CPR as literally defined. Other options include intensive care, antibiotic therapy, hydration, and nutritional support. Appropriate comfort measures should be employed for all patients, especially terminally ill patients.
Ohio Revised Code Chapter 2133
The hospital addresses the wishes of the patient relating to end-of-life decisions
Cleveland Clinic Advance Directive Policy
Department of Bioethics
Office of General Counsel
DNR Task Force / Reviewed 8/11/05
G. Agich, Ph.D.
S. Paschke, RN
L. Capone, RN
A. Thomas, MD