OBJECTIVE: To assure that patient welfare is protected and that appropriate actions are taken when decisions to refrain from attempting cardiac and/or pulmonary resuscitation are made by the patient, their surrogate, and/or the health care team. (See Determination of Decisional Incapacity and Surrogates for Patients policy)

POLICY:

1. The Do Not Attempt Resuscitation (DNAR) policy provides instruction/guidance to health care providers about decisions regarding the withholding of cardiopulmonary resuscitation efforts in the event of impending or sudden cardiac or respiratory arrest.
2. On admission, all patients will have a code status order and/or limitations of treatment (LOT) order placed.
3. All pre-printed orders will have Code Status and LOT selections
4. Code Status orders will consist of the following:
1. Full Code
2. DNAR

GENERAL INFORMATION

1. Attempting cardiac and/or pulmonary resuscitation (CPR) should be the standard of care unless otherwise indicated.
2. A DNAR order refers only to the suspension of CPR and does not refer to other forms of treatment or a reduction in the level of care.
3. Patient care personnel should notify the responsible physician(s) if approached by the patient/surrogate regarding a change in resuscitation status.
4. Consent to the DNAR status may be revoked at any time by the patient as long as they have decision-making capacity, or by their surrogate should the patient not be able to represent him or herself.
5. When a change in service occurs, a DNAR order should be maintained without disruption unless revoked by the patient or their surrogate in the event of patient incapacity.
6. If DNAR is no longer indicated, or has been rescinded, then an order should be written at the time of transfer rescinding the DNAR order, accompanied by documentation as to why.
7. Out of Hospital Do Not Resuscitate Orders (OHDNR), that come with the patient on admission to the hospital, should be respected and automatically applied until the patient or their surrogate revokes them.
8. When OHDNR orders come with the patient to the hospital this status should be reconfirmed with the patient or their surrogate and a new DNAR order should be written within 48 hours of admission.
9. DNAR status should terminate upon discharge from the hospital unless otherwise specified by a physician’s order.
10. If an OHDNR order came with the patient on admission, DNAR status will be communicated to the facility and healthcare providers who will be assuming treatment responsibility for the patient following discharge.
11. When a patient is to undergo operative, diagnostic, or therapeutic procedures that place them at risk for cardiac or pulmonary arrest, the physician doing the procedure should clarify with the patient and/or surrogate the meaning of the DNAR order in the context of balancing the specific risk(s) and potential benefits of the procedure(s).
12. The medical record should then reflect that the patient’s DNAR status has subsequently been reviewed, retained, and/or modified prior to undergoing the procedure.
13. In some cases, performance of a procedure may require that intubation, ventilatory support, or other life system support be provided in order to safely complete the procedure in a patient with a DNAR order (e.g., support for a patient undergoing a procedure that requires deep sedation or anesthesia). 
14. Although such a process would not normally be considered resuscitation, permission to provide such support should be obtained by the procedural physician or the anesthesiologist/anesthetist at the time of obtaining consent for the procedure.
15. Conflicts or disagreements regarding DNAR orders should be resolved before the order is written. 
16. Assistance may be obtained by contacting Social Services, Pastoral Care, or the Clinical Ethics Consult Service. 
17. You may reach the ethicist on call through the hospital operator or by calling the Center for Health Ethics (882-2738) during normal working hours.
18. Advance Directives serve as a general guideline regarding the patient’s wishes at the end of life and should be offered to the patient if they have decision-making capacity as part of the DNAR decision-making process.
19. When the patient reaches the patient care area, the nursing staff is responsible for clarifying and indicating any documented limitations of treatment by placing a purple wristband on the patient. 
20. Each patient that has current physician orders in their medical record that delineate limitations of treatment, including DNAR, will have a purple alert band placed with “DNAR” hand written on the band.
21. Changes in the patient’s clinical status may require reevaluation of the DNAR order. Changes in DNAR status will be written as a new order in the medical record.

PROCEDURE:
Responsibilities of Physician (Attending, Fellow or Resident)

1. Review Advance Directive in the patient’s chart
2. Evaluate medical condition of the patient
3. Educate the patient/surrogate about diagnosis/prognosis, risks, potential benefits of attempting  CPR, range of resuscitation measure and the consequences of the DNAR order
4. Document DNAR on the pre-printed physician order sheet.
5. The order will withhold all of the following unless specifically ordered otherwise:
1. Anti-Arrhythmics/ pressors
2. Invasive (intubation) or life-saving non invasive mechanical ventilation
3. Chest compression/CPR
4. Defibrillation
5. Other limitations should be listed separately in the general physician orders
6. Initial DNAR orders must be written.
7. The House Officer may write orders after consultation with the Attending Physician. 
8. The conversation must be documented in the progress notes or on the DNAR Form.
9. The Attending Physician must cosign initial DNAR orders written by the House Officer or any subsequent modifications to the orders.
10. Document the following in the progress notes or on the DNAR Order Form:
1. Clinical indications for the order and prognosis
2. Acknowledge the presence or absence of the patient’s written advance directive and a brief notation as to the directives that place limitations on treatment
3. Discussions with the patient or their surrogate, noting the patient’s values, beliefs, and preferences pertaining to any limitation of treatment, including DNAR.
4. Discussion with the attending physician if the order is written by a resident or fellow.

Staff

1. The Unit clerk/nurse needs to transcribe the order.  
2. The Unit clerk/Nurse will note the order and accomplish the following:
1. Enter the Code Status Order into PowerChart by selecting the DNAR order from the Care Sets group and signing the order.
1. Transcribe the order
2. Place a piece of purple tape on the side of the order sheet where the physician order is written as well as on the preprinted DNAR order sheet so that it can be easily found by anyone needing it.
3. Place a purple sticker on the front cover of the hard chart indicating DNAR to match the color of the patient’s armband.
2. If the unit does not use PowerChart, the Unit Clerk/Nurse will sign/date the order and accomplish the following:
1. Transcribe the order
2. Place a piece of purple tape on the side of the order sheet where the physician order is written as well as on the preprinted DNAR order sheet so that it can be easily found by anyone needing it.
3. Place a purple sticker on the front cover of the hard chart indicating DNAR to match the color of the patient’s armband.
3. The Unit clerk will give the nurse a purple armband for them to place on the patient.

Registered Nurse - Acknowledge the DNAR order by signature at the time it is written.

Nursing Staff

1. Apply a purple wristband, noting “DNAR” on the alert band.
2. Should it become necessary to remove the identification band from the original site, the person removing the band will be responsible for immediately replacing the band, or relocating it as necessary. 
3. If unable to place the band on an extremity due to complications, the band(s) may be placed on the urinary catheter as a last resort.
4. Inform the physician of changes in the patient’s condition and any requests for revocation of the DNAR order by the patient/surrogate.

Physician/Nursing Staff

Order expiration and review:

1. The DNAR order can be revoked at any time if clinically indicated or if requested by the patient/surrogate. 
2. In such a case, the purple DNAR band will be removed and discarded.

Key Content Expert: Chair, Patient Rights and Organizational Ethics

 Approved:

 _____________________________________                        7/1/08
                                         
Anita M. Larsen, Interim Chief Operating Officer                         Date
University of Missouri Health Care