Policy On Do Not Resuscitate
Resuscitation is a medical procedure which seeks to restore cardiac and/or respiratory function to individuals who have sustained a cardiac and/or respiratory arrest. "Do Not Resuscitate" ("DNR") is a medical order to provide no resuscitation to individuals for whom resuscitation is not warranted.
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 care measures should be employed for all patients, especially terminally ill patients.
DNR orders given at the Cleveland Clinic shall invoke a protocol hereinafter referred to as the DNR Protocol. The DNR Protocol has been adopted by the Ohio Department of Health as appropriate for statewide use and requires that emergency care and other health care providers:
- WILL suction the airway, administer oxygen, position for comfort, splint or immobilize, control bleeding, provide pain medication, provide emotional support, and contact other appropriate health care 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.
Types of DNR Orders
The diversity of patients, illnesses, and therapies requires that DNR orders be adaptable to specific circumstances. To ensure flexibility three types of DNR orders may be given for Cleveland Clinic patients:
- DNR Comfort Care
"DNR Comfort Care" orders activate the DNR Protocol at the time the order is given. DNR Comfort Care orders permit comfort care only both before and during a cardiac or respiratory arrest. Resuscitative therapies will not be administered prior to an arrest. This order is generally regarded as appropriate for patients who have a 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. A cardiac arrest occurs when there is an absence of a palpable pulse. A respiratory arrest occurs when there are no spontaneous respirations or there is agonal breathing. Resuscitative therapies will be administered before an arrest but not during an arrest. The term "DNR" (without additional wording) when recorded in the medical chart shall be considered a "DNR Comfort Care-Arrest" order. 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).
- DNR Specified
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.
Authority to Give a DNR Order
Although any physician and certain nurse practitioners legally may give DNR orders in Ohio, at the Cleveland Clinic only a patient's primary physician may give a DNR order. The primary physician is generally the first physician listed on the patient's data card. Primary physicians may delegate to physician residents the authority to record a DNR order in the medical chart.
Patient Consent to a DNR Order
DNR is a medical order to be given only by authorized health care practitioners. DNR orders generally should be given with the informed consent of the patient or the patient I s surrogate decision-maker. Ideally, the physician should sensitively discuss the DNR option with the patient while the patient is mentally competent. However, DNR orders are often considered for patients who are comatose or who otherwise lack decisional capacity with whom this discussion has not occurred or cannot occur. In cases when a patient lacks decisional capacity, the DNR option should be considered in conjunction with the patient's advance directives, if known, or should be discussed with a surrogate. A surrogate may be designated by a patient as the attorney-in-fact in a Durable Power of Attorney for Health Care. A surrogate may also be identified as the first available person(s) from the following list, in order: legal guardian, spouse, majority of adult children, parents, majority of adult siblings, or other nearest adult relative. In all cases the primary physician should discuss the DNR option with the patient if possible and the surrogate(s) if appropriate. There is no 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, and would violate reasonable medical standards.
Recording the DNR Order in the Medical Chart
The words "DNR Comfort Care," "DNR Comfort Care-Arrest," 'or "DNR Specified" should be recorded on the "left-hand side" of the medical chart (where advance directives are maintained) along with 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. If a DNR Specified order is recorded, the modifications to the DNR Protocol should be specified in the medical chart, as well as the desired timing of the activation of the modified Protocol.
DNR decisions for inpatients should be transmitted clearly to those caring for the patients. A DNR order should never result in the abandonment of a patient, and steps should be taken to assure that abandonment is not perceived.
Cleveland Clinic DNR Identification Bracelet
All Cleveland Clinic inpatients for whom a DNR order has been given will wear a Cleveland Clinic DNR identification wrist bracelet. Such identification is intended to facilitate communication and direct care to comply with DNR orders previously given, especially in emergencies. Cleveland Clinic DNR identification bracelets will be uniform in color and style. They will contain the inpatient's name, Cleveland Clinic patient history number, and the preprinted designations of the three types of DNR orders. The type of DNR order given for a particular inpatient will be holepunched through that patient's bracelet. All Cleveland Clinic inpatients who have a DNR order will wear a Cleveland Clinic DNR identification wrist bracelet regardless of whether they are also wearing a state-approved DNR bracelet (see Ohio Portability Rules below).
Cleveland Clinic DNR Informational Pamphlet
An informational pamphlet which explains Cleveland Clinic's policy and Ohio law regarding DNR orders will be available to all Cleveland Clinic inpatients and outpatients who have a DNR order. The pamphlet will include 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 will encourage patients and family members to ask their physicians any questions they may have about DNR.
Reassessment and Revocation of DNR Orders
The DNR order should be reassessed as part of the ongoing evaluation of an inpatient. A DNR order should be affirmed, modified, or revoked only after a discussion between the primary physician and the patient, if possible, or the surrogate(s) if appropriate, and the consent of the patient or surrogate. DNR orders should be reassessed frequently and as conditions warrant. Reassessments of DNR orders should be documented in the medical chart. If a DNR order is changed from one of the three types of DNR orders to a different type, the patient's Cleveland Clinic DNR bracelet should be replaced with a new bracelet containing the revised designation. If a DNR order is revoked, the Cleveland Clinic DNR bracelet should be removed and destroyed. A physician or other health care worker who feels that he or she cannot honor a patient's DNR request may not prevent or delay the transfer of the patient to a physician or facility which will honor the DNR status.
Invasive Procedures and Anesthesia Care
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 the documentation of informed consent, any existing DNR order should, when possible, be reviewed with the patient or the patient's surrogate. 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. Any clarifications or modifications should be documented in the medical chart along with a notation indicating if or when the original DNR order should be reinstated. Concurrence on these issues by the primary physician, the surgeon, and the anesthesiologist is desirable. The Cleveland Clinic DNR bracelet should not be removed during the perioperative period, even if the DNR order has been temporarily modified.
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 an Attorney-in-Fact) ranked higher in the following list shall prevail:
- Living will of a person who is in a 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.
- DNR order.
The three types of DNR orders are for use within the Cleveland Clinic and probably would not be honored outside the Cleveland Clinic. However, some patients wish to have DNR orders travel with them, or be "portable." "DNR Comfort Care" and "DNR Comfort Care-Arrest" orders may be made portable and should be honored statewide by EMS and other emergency care workers outside the Cleveland Clinic if the following procedures are followed by the primary physicians giving the DNR orders. Note: "DNR Specified" orders cannot be made portable.
Patients should be provided with one of the following state-approved forms of DNR identification: (1) a DNR identification form, (2) a transparent hospital-type bracelet with an insert, (3) a wallet card, or (4) a prescription for either a bracelet or necklace manufactured pursuant to specifications of the Ohio Department of Health. All of these forms, which are available at the Cleveland Clinic, contain at least the patient's name and the state-approved DNR Comfort Care logo depicted below. Copies of any state-approved forms of DNR identification should be inserted on the "left-hand side" of the medical chart (where advance directives are maintained). Cleveland Clinic inpatients who have state-approved DNR identification (including bracelets) also will wear Cleveland Clinic DNR identification bracelets.
(Insert State-Approved DNR Comfort Care Logo)
Patients who request state-approved DNR identification should be given a Cleveland Clinic DNR Informational Pamphlet and be fully informed about the effect of their DNR orders and how emergency medical services personnel will respond to their type of DNR order. The type of DNR order, the medical reasons for the DNR order, and a statement that the patient or surrogate was fully informed about and consented to the DNR order should be recorded in the medical chart.
CCF Hospilal Admissions and Trans
State-approved DNR identification forms, bracelets, and necklaces of any patients admitted to Cleveland Clinic Hospital should be honored (see Ohio Portability Rules). The DNR status of these patients should be reassessed upon admission, and the patients should be given Cleveland Clinic DNR identification bracelets.
Cleveland Clinic must notify the receiving facility and the transport team of the state-approved DNR status of any patient which Cleveland Clinic transfers to that facility.
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.