DNR Order Management in Pediatric Patients
DNR orders should be reviewed periodically based on the patient's condition, particularly when clinical status changes, as they are not permanent lifetime orders. 1
Key Management Principle
The American Heart Association guidelines explicitly state that DNAR orders should be reviewed periodically as per local protocol, particularly if the patient's condition changes. 1 This is the standard of care for all DNR orders, including those in pediatric patients with permanent neurological conditions.
Why DNR Orders Require Ongoing Review
Clinical conditions evolve: Even in children with permanent brain damage and white matter disease, the clinical trajectory may change, requiring reassessment of goals of care 1
Family perspectives may shift: The American Academy of Pediatrics emphasizes that ongoing communication with families is critical, as their understanding and wishes may evolve over time 1
DNR orders are medical orders, not permanent directives: They must be actively maintained through physician review and documentation 1, 2
Specific Review Triggers
DNR orders should be reviewed when:
The patient's clinical condition changes significantly (improvement or deterioration) 1
Before any surgical or procedural intervention, requiring discussion between the anesthesiologist, attending surgeon, and patient/surrogate 1, 3
At regular intervals per institutional protocol (not necessarily at fixed time intervals like every 3 months, but based on clinical need) 1, 2
Common Pitfall to Avoid
Do not assume DNR orders are "valid for life" or permanent. 1 This is a critical error that can lead to inappropriate care decisions. Even in cases of severe permanent neurological damage, the DNR order remains a dynamic medical order requiring active physician oversight and periodic reassessment based on the child's evolving clinical status and family goals of care.
Documentation Requirements
Each review should include:
Documented discussion with family/surrogate decision-makers about current clinical status and goals 1, 2
Clear notation of the rationale for continuing, modifying, or revoking the DNR order 1, 2
Specific instructions about which interventions are withheld and which continue 1
The correct answer is B: DNR is reviewed based on patient's condition.