DO NOT RESUSCITATE(DNR)

GUIDELINES FOR â DO NOT RESUSCITATEâ (DNR) ORDERS

I. Rationale and Objectives
The utilization of cardiopulmonary resuscitation (CPR) has become routine in alm
ost all hospitals in the United States but still not in practiced in this hospi
tal routinely except in ICU , however MOH GUIDELINES determine that donâ t resuscita
te if there is surety of death of a person In fact, it is one of the few medica
l interventions which can not be undertaken without a physician's order. Yet, wh
en effectiveness of CPR is measured in terms of the patient's surviving to the p
oint of discharge from the hospital, studies of CPR of hospitalized patients dem
onstrate only a 5% to 20% success rate. This rate is even lower in selected pati
ent populations such as those with metastases cancer, chronic debilitating illne
ss or multiple organ failure. These guidelines recommend the procedures to be fo
llowed in making and implementing a decision to withhold utilization of these em
ergency resuscitation techniques. If a patient has included directives regarding
such treatment as part of an "advance directive" such as a Living Will, the pro
visions of that declaration and related legislation will apply.
II. Definitions
"Competent Adult Patient" - patient of at least eighteen years of age who is det
ermined to have the capacity to make his/her own treatment decisions, i.e. the c
apacity to understand relevant information, reflect on it in accordance with his
/her values, and communicate with caregivers. "Incompetent Adult Patient" - pati
ent who has been legally declared incompetent or a patient who is determined to
have an irreversible lack of decision making capacity.
"Pediatric Patient" - patient of less that eighteen years who is not otherwise l
egally emancipated. "Cardiopulmonary Resuscitation" - emergency treatment of acu
te failure of cardiac or respiratory systems (cardiac and/or respiratory "arrest
") usually including at least one of the following procedures: chest compression
s ("closed chest" cardiac massage)intubations/ventilation, and cardiac defibrill
ation.
III. Procedures for Implementation
A. Guidelines for Decision making
Evaluation and Discussion - A DNR order should be considered in any clinical sit
uation in which resuscitation would likely be futile or in which the utilization
of such treatment would be inappropriate in view of the patient's diagnosis and
/or prognosis. The patient's attending physician has the primary responsibility
to evaluate the patient and to facilitate discussion with patient and/or family
in situations in which such an order is judged to be appropriate. Nursing staff
can also play an important role in this evaluation process and in supporting dis
cussion with patient and/or family.
Identification of Decision-maker - If the patient is a competent adult, discussi
on and decision- making regarding a DNR order need only involve the patient. A D
NR order for such a patient should be written only with his/her informed consent
. If the patient has been adjudged to be mentally incompetent by a court, the pr
imary decision-maker is the patient's guardian. If the patient is determined to
lack the capacity to participate in the decision-making process, the physician s
hould determine if the patient had previously indicated a choice of the appropri
ate individual to act as decision-maker or seek to identify a member of the pati
ent's family who will act as a surrogate decision-maker.
Making the Decision - The decision about the DNR order should be made in accorda
nce with the expressed wishes of the patient or in accordance with the explicit
directives of the patient, i.e. "advance directives" or in accordance with the k
nown preferences and values of the patient. Lacking any of the above, the decisi
on should be based on a careful and reasoned consideration of the patient's inte
rests.
Pediatric Patient - Decision-making regarding utilization of CPR for pediatric p
atients should be made according to the previously approved guidelines.
Conflict/Disagreement - Since decision-making regarding DNR orders will frequent
ly involve shared responsibility, there may be situations in which there is disa
greement among health care providers or between providers and surrogate decision
makers regarding the appropriateness of a DNR order. Such disagreements should
be discussed and examined thoroughly and efforts made to achieve agreement. If t
hey cannot be resolved, additional consultation and/or referral to the Ethics Co
mmittee should be considered.
B. DNR Orders
All orders not to resuscitate must be written or signed by the patient's attendi
ng physician on the Physician's Order Sheet. It is imperative that caregivers an
d patients/families realize that resuscitative measures (calling a "Code Blue" a
nd initiation of CPR) will be performed routinely on all patients for whom there
is not a written DNR order. In addition to the order "Do Not Resuscitate (DNR)"
, the physician may wish to modify the order by including instructions regarding
specific resuscitative interventions.
Verbal DNR orders can be received only by a licensed physician and must be witne
ssed. Verbal or telephone orders must be countersigned within 12 hours by the at
tending physician who gave the order.
C. Documentation
In addition to the order itself, physicians must make certain that the patient'
medical record provides adequate documentation of the evaluation, discussion a
nd
decision-making process. A specific entry attendant to the order should be con
sidered which includes: a short description of the patient's condition.