CCF Implementation of the New Ohio "DNR Comfort Care" Rules and Regulations

In May 1999, Ohio enacted a do-not-resuscitate law and governing rules known as "DNR Comfort Care." A new Policy on Do Not Resuscitate Orders approved by the Board of Governors in September 1999 will be implemented beginning April 3, 2000.

While DNR orders have been written by physicians for decades, the validity of DNR orders in some settings (e.g., a patient's home) and the transfer of DNR orders across settings (e.g., from a hospital to a nursing home) have been questioned. The "DNR Comfort Care" law remedies this uncertainty by creating a standard protocol and forms of identification that can be honored throughout Ohio.

Under the new Ohio law, the "DNR Comfort Care" protocol requires that professionals:

WILL suction the airway, administer oxygen, position for comfort, splint or immobilize, control bleeding, provide pain medication, provide emotional support, and contact other appropriate providers; and
WILL NOT administer chest compressions, insert an artificial airway, administer resuscitative drugs, defibrillate or cardiovert, provide respiratory assistance (other than suctioning the airway and administering oxygen), initiate resuscitative IV, or initiate cardiac monitoring.

Also, under the new Ohio law, two options for DNR orders are recognized, and CCF has established a third option. The three options are:

  1. DNR Comfort Care (DNRCC) orders permit comfort care only (the above protocol), both before and during a cardiac or respiratory arrest. This kind of order is generally appropriate for a patient with a terminal illness, short life expectancy, or little chance of surviving CPR.
  2. DNR Comfort Care - Arrest (DNRCC-Arrest) orders permit the use of all resuscitative therapies before an arrest, but not during or after an arrest. A cardiac arrest is defined as an absence of palpable pulse. A respiratory arrest is defined as no spontaneous respirations or the presence of agonal breathing. Once an arrest is confirmed, all resuscitative efforts should be stopped and (following the above protocol) comfort care alone initiated.
  3. DNR - Specified orders allow the physician to "tailor" the DNR order to the specific circumstances and wishes of the patient. For example, under this option the physician could specify "pharmacological code only," or "no defibrillation, or "do not intubate."

Options 1 and 2 (DNRCC, and DNRCC - Arrest) can be made portable, i.e., under Ohio law they can travel with the patient from one care setting to another. Option 3 (DNR - Specified) is not portable.

Attention should be given to patients admitted or discharged with DNR orders so that all involved health professionals understand what kind of DNR order has been written. For patients admitted with a state-approved DNR order, the primary physician must re-assess and re-write the order to conform to CCF policy. If a patient survives to discharge, the DNR order should be re-written in accord with patient wishes and according to state-approved options. Transport personnel and the receiving facility must be notified about the DNR order.

The Ohio DNR Comfort Care regulations permit various means of identification to communicate the patient's code status: 1) a state-approved DNR Comfort Care form, signed by a physician or advanced practice nurse; 2) a DNR necklace or bracelet; 3) a DNR wallet card; or 4) a Living Will specifying that a DNR order should be written when the Living Will becomes effective.

In the CCF hospital, all patients with a DNR order will wear a yellow, hospital-style bracelet indicating the kind of DNR order written. A new CCF DNR Order form entitled End of Life Decision Making should be used for writing all DNR orders. A patient brochure about DNR Comfort Care protocol is available. Prior to an invasive procedure and anesthesia, an existing DNR order should be re-assessed, when possible, with the patient or surrogate. A CCF Reassessment of Do Not Resuscitate Order During Invasive Procedures form should be completed by the ordering or primary staff physician.

The CCF Policy on The DNR Order is available in Last Word and on the CCF Intranet. The CCF DNR Nursing Procedure Protocol is available on the CCF intranet. The End of Life Decision Making Order forms will be available at all nursing units. A Patient DNR information brochure entitled, "Do Not Resuscitate" Orders and Comfort Care can be ordered from the Storeroom.

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