DO NOT RESUSCITATE (DNR) FREQUENTLY ASKED QUESTIONS .docx

DO NOT RESUSCITATE (DNR):
FREQUENTLY ASKED QUESTIONS
WHAT DOES DNR MEAN?
DNR stands for “do not resuscitate.” A person who does not
wish to have
cardiopulmonary resuscitation (CPR) performed may make this
wish known through a
physician’s order called a DNR order. A DNR order addresses
the various methods
used to revive people whose hearts have stopped functioning or
who have stopped
breathing. Examples of these treatments include chest
compressions, electric heart
shock, artificial breathing tubes and special drugs. These
standardized DNR orders
allow patients to choose the extent of the treatment they wish to
receive at the end of
life. A patient may choose to be DNR Comfort Care (DNRCC)
or a DNR Comfort Care
– Arrest (DNRCC-Arrest).
DOES OHIO HAVE A LAW CONCERNING DNR ORDERS?
Yes. Ohio adopted a law concerning DNR orders in 1998.

HOW CAN I GET A DNR ORDER?
An individual may obtain a DNRCC by consulting with his or
her physician regarding
end-of-life issues. The DNRCC allows this specific DNR order
to be used in multiple
settings and practice areas including but not limited to nursing
facilities, residential care
facilities, hospitals, outpatient areas, homes and public places.
For a DNR order to be
useful in multiple settings, it must be recognizable by health
care workers. The Ohio
Department of Health (ODH) has developed a standard form that
is generally
recognized. Unlike a living will and health care power of
attorney, a DNR order must be
written and signed by a physician or an advanced-practice nurse
after consultation with
the patient.
DNR FREQUENTLY ASKED QUESTIONSPAGE 1 OF 4
PAGES
WHAT IS THE DNR PROTOCOL?
The DNR protocol lists the specific actions paramedics,
emergency medical technicians,
physicians or nurses will take when attending to a DNR patient.

The protocol also
specifies actions that will not be implemented. The standard
DNR protocol is to be used
for a patient whose physician or advanced-practice nurse has
written a DNR order.
THE DNR PROTOCOL – WHEN IS IT ACTIVATED?
Under the DNR protocol, a patient must choose between
DNRCC and DNRCC – Arrest
status, which in turn, determines when the DNR protocol is
activated:
1) DNR Comfort Care (DNRCC) – a person receives any care
that eases
pain and suffering, but no resuscitative measures to save or
sustain life.
This protocol is activated immediately when a valid DNR order
is issued
or when a living will requesting no CPR becomes effective.
2) DNR Comfort Care – Arrest (DNRCC-Arrest) – a person
receives
standard medical care until the time he or she experiences a
cardiac or
respiratory arrest. Standard medical care may include cardiac
monitoring
or intubation prior to the occurrence of cardiac or respiratory
arrest. This
protocol is activated when the patient has a cardiac or
respiratory arrest.

“Cardiac arrest” means absence of a palpable pulse.
“Respiratory arrest”
means absence of spontaneous respirations or presence of
agonal
breathing.
Once the protocol is activated, the health care provider
WILL:
• Suction the airway
• Administer oxygen
• Provide pain medications
• Position for comfort
• Splint or immobilize
• Control bleeding
• Provide emotional support; contact other health care providers
WILL NOT:
• Start chest compressions
• Insert an artificial airway
• Administer resuscitaiton drugs
• Defibrillate or cardiovert
• Administer respiratory assistance
PAGES
• Use resuscitative IV lines
• Initiate cardiac monitoring.

DOES DNR COMFORT CARE MEAN “DO NOT TREAT?”
The DNRCC protocol is very specific in terms of what treatment
is to be given and what
treatment is to be withheld. Only those items listed on the “will
not” list are to be
withheld. The items listed on the “will” list, along with any
other treatment that may be
needed for the patient’s condition, may be provided as
appropriate.
CAN I SIGN MY OWN DNR ORDER?
No. A DNR order must be written and signed by a physician or
an advanced-practice
nurse after consultation with the patient.
CAN ANYONE ELSE OVERRIDE MY WISHES ABOUT CPR
EVEN THOUGH A
VALID DNR ORDER EXISTS?
No. You have the right to make your own decisions about your
health care. If you are
not able to express your wishes, other people such as a legal
guardian, a person you
name as your health care power of attorney, or a family member
can speak for you.
You should make sure these people know your desires about
CPR and that you have a
DNR order.
WHAT IF I CHANGE MY MIND AFTER MY PHYSICIAN
WRITES A DNR ORDER?

You always have the right to change your mind and request
CPR. If you do change
your mind, you should talk with your physician right away
about revoking your DNR
order. You should also tell your family and caregivers about
your decision.
IF I AM NOT ABLE TO DECIDE ABOUT CPR FOR MYSELF,
WHO WILL DECIDE?
First, two doctors must determine that you are unable to decide
about CPR. You will be
told of this determination and have the right to object.
If you become unable to decide about CPR, and you did not tell
your doctor or others
about your wishes in advance, a DNR order can be written with
the consent of someone
chosen by you, by a family member or by a close friend. The
person highest on the
following list will decide about CPR for you:
• The person chosen by you to make health care decisions
• A court-appointed guardian
• Your closest relative (spouse, child, parent, sibling)
• Close friend
PAGES

PAGES
UNDER WHAT CIRCUMSTANCES CAN A FAMILY
MEMBER OR CLOSE FRIEND
DECIDE A DNR ORDER SHOULD BE WRITEN?
A family member or close friend can consent to a DNR order
only when you are unable
to decide for yourself and you have not appointed someone to
decide for you. Your
family member or close friend can consent to a DNR order
when:
• You are terminally ill
• You are permanently unconscious
• CPR will not work (would be medically futile)
• CPR would impose an extraordinary burden on you given your
medical
condition and the expected outcome of CPR
Anyone deciding for you must base the decision on your wishes,
including your religious
and moral beliefs, or if your wishes are not known, on your best
interests.
HOW DOES SOMEONE KNOW I AM A DNR COMFORT
CARE PATIENT?
Your DNR order (your physician or advanced-practice nurse
will give you a copy) can
serve as evidence you are a DNRCC patient and you desire the
statewide standard

DNR protocol to be used at the appropriate time. A wallet ID
card and a hospital type
wristband also are available to identify you as a DNRCC
patient. You are not required
to carry the ID card or to wear an identification bracelet.
However, if a provider cannot
identify you as a DNRCC patient, all efforts to resuscitate you
and to sustain life will be
applied as this is an appropriate and legal response in the
absence of definitive DNR
identification.
Under the law, emergency medical services (EMS) workers are
not required to search
patients for DNR identification. However, if DNR
identification is discovered, the EMS
personnel must make reasonable efforts to verify the patient’s
identity. After
verification, the workers must honor the DNR directive and
follow the DNR protocol.
The law provides immunity to EMS workers who follow the
DNR directive.
WHERE CAN I GET A DNR COMFORT CARE WALLET ID
CARD OR BRACELET?
The DNRCC wallet ID card will be available through you
physician or advance-practice
nurse. The DNRCC hospital type identification wristband
(bracelet) is available from
hospitals, nursing homes and any other source with the
capability to fabricate this type
of bracelet. The format for the wallet ID and the bracelet insert
can be accessed at the
ODH Web site: http://www.odh.ohio.gov. ODH also maintains

a listing of commercial
agents who MAY be able to supply the bracelet, wristband or
necklace.
DNR-freq-quest rev 09/19/08
http://www.odh.ohio.gov/pdf/forms/dnr_card.pdf
http://www.odh.ohio.gov/pdf/forms/dnr_band.pdf
http://www.odh.ohio.gov/
http://www.odh.ohio.gov/ASSETS/0530DF92F8AF4BE7A1132B
D0D2066B17/Jewerly%20Resource%20List_08.pdf
http://www.odh.ohio.gov/ASSETS/0530DF92F8AF4BE7A1132B
D0D2066B17/Jewerly%20Resource%20List_08.pdf
Pediatric DNAR Orders and Public Schools
adolescents; A practical handbook, eds. B. S. Carter, and M.
Levetown, 141–162. Baltimore, MD: Johns Hopkins University
Press.
Schindler, M. B., D. Bohn, P. N. Cox, B. W. McCrindle, A.
Jarvis,
J. Edmonds, and G. Barker. 1996. Outcome of out-of-hospital
cardiac or respiratory arrest in children. New England Journal
of Medicine 335:1473–1479.
Savage, T. A. 2005. DNAR in Schools: Questions and concerns.
The American Journal of Bioethics 5(1): 72–74.
Silvers, A. 2005. Going to die: Equal treatment for well and ill
children. The American Journal of Bioethics 5(1): 69–71.

Slonim, A. D. 2000. Cardiopulmonary outcomes in children.
Critical Care Medicine 28:3364–3366.
Torres A., C. B. Pickert, J. Firestone, W. M. Walker, and
D. H. Fiser. 1997. Long-term functional outcome of inpatient
pediatric cardiopulmonary resuscitation. Pediatric Emergency
Care 13:369–373.
Viens, A. M., and J. R. Bibbee. 2005. Legal frameworks for ad-
dressing the well-being of terminally ill children. The American
Journal of Bioethics 5(1): 74–76.
Young, K. D., M Gausche-Hill, C. D. McClung, and R. J. Lewis.
2004. A prospective, population-based study of the epidemiol-
ogy and outcome of out-of-hospital pediatric cardiopulmonary
arrest. Pediatrics 114:157–164.
Youngner, S. J. 2005. School DNAR in the real world. The
Amer-
ican Journal of Bioethics 5(1): 66–67.
Copyright c⃝ Taylor & Francis, Inc.
DOI: 10.1080/152651690927926
The Spectrum of Our Obligations: DNR in Public Schools
Kathryn L. Weise, Cleveland Clinic Foundation
Kimberly et al. (2005) have examined an important issue
surrounding end-of-life decision-making, that of honoring
do-not-resuscitate (DNR) orders in the non-medical setting
of public schools. Their data reveals that as a country, we
either have little agreement on its appropriateness, or have
little awareness of its implications for families facing ter-
minal illness of a child who remains able to attend school.
The article is timely in an era when more children with

serious medical problems survive, and when palliative care
principles encourage parents to address end-of-life issues
proactively. They conclude that the development of “just”
school policies will require further discussion, and that only
through open and cooperative efforts can we honor family
decisions not to pursue resuscitation. I would further ar-
gue that these decisions should be honored based on a duty
to protect vulnerable children—but that this imposes clear
obligations on both medical and non-medical stakeholders.
The most pertinent position statement on this issue is
that of the American Academy of Pediatrics (AAP 2000). It
states that it is the intent of the AAP that its members “re-
spond to the changing needs of their patients,” and that this
may involve “guidance and advice that will continue educa-
tion and participation for as long as reasonable.” Feudtner
et al. (2000, 2001, 2002) have studied changing patterns
of child death, illustrating that while more children with
complex chronic conditions now survive, more are also dy-
ing outside of the hospital. The reasons for these trends
remain poorly defined, but still have implications for this
discussion. As awareness of palliative care principles has in-
creased within the field of pediatrics, end-of-life planning
for children with terminal disease has become more openly
discussed. When a carefully considered do-not-resuscitate
directive is in a child’s best interest, caregivers serve this
child’s best interest by honoring it. Two cases will help
frame the issue.
CASE I
Carrie is a seven year-old born with severe congenital heart
disease. With the advice of physicians and their spiritual
community, her parents agreed to aggressive support. She
underwent three surgical procedures by age three to palliate

her heart disease. Each operation involved prolonged hospi-
talization because poor muscle tone and difficulty feeding
prolonged recovery each time. Developmental delays grad-
ually became apparent.
At age eight months she developed hydrocephalus and
required placement of a ventriculoperitoneal shunt. Shunt
revisions were needed at ages one year, eighteen months,
two years, three years, and five years because of shunt mal-
function or infection, each time requiring a two-day to
three-week hospitalization. She later developed a severe
seizure disorder resulting in two to three brief seizures each
day despite medications. The seizures, high doses of med-
ications, and frequent hospitalizations further delayed her
development. At five years of age her heart function be-
gan to fail. She was not approved for heart transplantation
because of her severe neurological disease.
Her medical care team included cardiologists, cardiac
surgeons, gastroenterologists, epileptologists, developmen-
talists, social workers, and a primary care pediatrician. She
had been in a stable public school setting with accommo-
dations for children with special needs since the age of five
Volume 5, Number 1 ajob 81
The American Journal of Bioethics
years. Because her family was facing difficult decisions and
felt the strain of multiple caregivers, a pediatric palliative
care specialist was involved to help coordinate care and to
help the family with decision-making.
Her parents described the situation as a choice between

“terrible options”—allowing her to die naturally, or con-
tinuing to subject her to medical care that was distressing
to her and which she could not understand. They stated
that each time she was hospitalized she lost ground. On
the other hand, when able to be at home and in school,
she “blossomed.” After lengthy discussion, Carrie’s par-
ents decided to forego further aggressive interventions. Two
months later, when more comfortable discussing end-of-life
issues, they requested a DNR order, and planned to keep
her in school as long as it added to her quality of life.
CASE II
Robert was a seventeen year-old with Duchenne’s muscular
dystrophy and progressive lung and heart involvement.
Throughout his illness, his parents and physicians had
involved him in medical discussions appropriate to his
developmental age. He became wheelchair-bound at age
ten, underwent tracheostomy at twelve years of age and
became ventilator dependent at age fifteen, but had been
able to attend school with intermittent absences. Robert
considered but refused evaluation for heart transplantation
when his heart disease became symptomatic at age sixteen,
but since his medical team recognized that his opinion
might change over time, it was re-addressed periodically.
When his pulmonary complications eventually precluded
listing for heart transplantation, his terminal condition
was discussed frankly. A “portable” DNR order was
written, yet he requested continuing in school as long as
possible because this was a major factor in maintaining
his own sense of well-being. He and his parents knew he
would die, and it was their intention that he would die
at home with hospice involvement. He did not anticipate
dying in school, but knew that a sudden event in that
setting, such as an acute dysrhythmia, was possible. He
did not want resuscitation, and particularly did not want

this done in front of peers.
THE SPECTRUM OF OUR OBLIGATIONS
As Feudtner’s earlier work suggests, anticipated deaths are
no longer confined to hospitals. Though the absolute num-
ber of children with complex disease who die outside of the
hospital setting remains small, the trend suggests that it is
increasingly acceptable to families for death to occur in a
setting other than the hospital. It is doubtful that a family
or child would prefer death in a school setting rather than
at home or in hospital, but the alternative of inadvertent
resuscitation outside of the home or hospital when a termi-
nal illness exists may be far worse. Though withdrawal of
support after resuscitation may be ethically equivalent to
never initiating that support in a case or terminal illness, it
is clearly more emotionally devastating for an already dis-
tressed family. This is the scenario that families who choose
DNR orders seek to avoid—unnecessary and potentially
painful interventions and escalation of support on the path
to the same inevitable outcome.
The argument for allowing CPR orders to stand in non-
medical settings is one of a duty to protect, in this case
protection against unwarranted medical interventions. Re-
suscitating against carefully considered wishes is a major
breach of a care plan felt by the primary stakeholders to be
in the child’s best interest. Other stakeholders need to be
considered, but they also have obligations to all involved.
But the devil is in the details—how do we follow an appro-
priate plan for a child while protecting caregivers and by-
standers such as other children from the trauma of watching
death, or from the uncertainty of whether non-resuscitation
was appropriate at a critical moment?

First, since DNR orders for children with terminal ill-
ness arise from physicians and parents working together,
both are obligated to insure that the order is appropriate,
clearly documented, and available when it is needed. Par-
ents of children with special health care needs search for
clarity and understanding, even when the topics are upset-
ting (Wharton 1996). The practice of pediatric palliative
care begins when a life-threatening condition is recognized,
and contracts with a family to follow through in all aspects
of care identified by a child’s caregivers as long as needed
to optimize the quality of a child’s remaining life. This in-
cludes coordinating an understanding of the child’s needs,
and recognition of what will no longer benefit that child
(Himelstein 2004). An obligation stemming from these
principles is sharing information about the reasons for a
DNR order with those asked to honor it.
What are the corollaries of our duty to protect?
! Physicians, parents, and hospice staff should be involved
in working with school staff and families to the extent
needed to protect the child against unwarranted resusci-
tation. This might include both a protocol for that school,
as well as written guidelines particular to that student’s
situation.! A family has an obligation to keep the child home
from
school during times of anticipated instability, to protect
against uncertainty and to shield school staff from dealing
with the issues as much as is feasible without isolating
the child from a valuable part of life.! Should school personnel
be bound to honor a DNR or-
der if “personal values collide with public obligations”
(Miller-Theil 1998)? This is a harder question—but
I believe that a duty to protect against unwarranted
82 ajob Volume 5, Number 1

Pediatric DNAR Orders and Public Schools
interventions also extends to non-medical personnel, to
the extent to which they can recognize that as the situa-
tion. In addition, if individual staff members feel morally
unable to honor the order, they should be honest about
it, giving the family the opportunity to develop an alter-
native plan such as keeping the child out of that school.! The
palliative care system should provide bereavement
care not only to the family, but also to school staff and
students directly affected by the death.
Rather than abandoning the possibility of honoring DNR
orders in schools, we should acknowledge our duty to pro-
tect children from painful and ineffective interventions at
the end of life. Our efforts should concentrate on tailoring
anticipated situations to the needs of a dying child who still
benefits from social involvement. Through recognizing the
obligations of all involved, we can provide continuity of hu-
mane care throughout the remainder of each child’s life. !
REFERENCES
American Academy of Pediatrics Committee on School Health
and Committee on Bioethics. 2000. Do not resuscitate orders
in schools. Pediatrics 105(4): 878–879.
Feudtner, C., D. A. Christakis, and F. A. Connell. 2000. Pe-
diatric deaths attributable to complex chronic conditions: A
population-based study of Washington State, 1980–1997. Pe-
diatrics 106(1): 205–209.
Feudtner, C., R. M. Hays, G. Haynes, J. R. Geyer, J. M. Neff,

and T. D. Keopsell. 2001. Deaths attributed to pediatric com-
plex chronic conditions: National trends and implications for
supportive care services. Pediatrics 107(6): 887–893.
Feudtner, C., M. J. Silviera, and D. A. Christakis. 2002. Where
do children with complex chronic conditions die? Patterns in
Washington State, 1980–1998. Pediatrics 109(4): 656–660.
Himmelstein, B. P., J. M. Hilden, A. M. Boldt, and D.
Weissman.
2004. Medical progress: Pediatric palliative care. New England
Journal of Medicine 350(17): 1752–1762.
Kimberly, M. B., A. L. Forte, J. M. Carroll, and C. Feudtner.
2005. Pediatric do-not-attempt-resuscitation orders and pub-
lic schools: A national assessment of policies and laws. The
American Journal of Bioethics 5(1): 59–65.
Miller-Theil, J. 1998. Do not resuscitate (DNR): State policies
for at-home and in-school. Pediatric Nursing 24(6): 599 ff.
Wharton, R. H., K. R. Levine, S. Buka, and L. Emmanuel. 1996.
Advance care planning for children with special health care
needs: A survey of parental attitudes. Pediatrics 97(5): 682–
687.
Copyright c⃝ Taylor & Francis, Inc.
DOI: 10.1080/152651690927971
Nurses at the Helm: Implementing DNAR Orders
in the Public School Setting
Gladys White, Georgetown University
Authors Kimberly, Forte, Carroll, and Feudtner (2005) have
done a service both in completing their survey of state laws
and school policies concerning DNAR orders within the

school setting and in suggesting a national stakeholder
conference to formulate integrated school, state and fed-
eral strategies. Contrary to their assertion, however, that
no assessment of these policies has yet been made, school
nurses have conducted surveys and been involved with this
issue for a number of years. In her article entitled “Managing
DNR Requests in the School Setting,” Carol Costante, RN,
MA, C.S.N., reports on a survey conducted by the National
Association of School Nurses in 1994 and two surveys of
local school districts conducted in 1995. “Of the 40 states
that responded to the 1994 survey, only three states (7.5%)
confirmed that they had statewide school DNR policies,
eight of the states (20%) indicated that there was one or
more local school district policies in their states, and two
states (5%) said that the development of local policies was
in progress” (Costante 1998, 50). Even though the study
sample in 1994 and the study sample reported by target ar-
ticle authors Kimberly et al. (2005) varied considerably, it
would appear that the situation with respect to policies and
procedures for DNAR orders in the public schools has not
changed radically in the past 10 years. The current authors
report that “most (80%) of school districts that they sam-
pled did not have policies’ regulations or protocols for deal-
ing with student DNARs (and) a similar majority (76%)
either would not honor student DNARs or were uncertain
about whether they could” (Kimberly et al. 2005, 1).
In addition to overlooking prior survey work that has
been conducted by the National Association of School
Nurses and others on DNAR policies in the schools, the
authors of the target article appear to overlook the pivotal
role that school nurses play with respect to DNAR orders as
well as in the delivery of school healthcare in general. Treat-
ments for children in schools these days include suctioning

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