Perform CPR Immediately in This Newborn
You must initiate full resuscitation immediately, including CPR if needed, because a DNR order that was discussed but never formally completed has no legal validity and cannot guide clinical decision-making. 1
Legal and Ethical Framework
Without a valid, signed, and dated DNR order, there is no documentation to support withholding resuscitation. 1 The American Heart Association guidelines are explicit that CPR should only be withheld when there is:
- A valid, signed, and dated advance directive or DNAR order 1
- Obvious clinical signs of irreversible death (rigor mortis, decomposition, decapitation) 1
- Situations where CPR would place the rescuer at serious risk 1
None of these conditions are met in this case—the discussion occurred but the order was never completed, making it legally non-existent. 1
Why Full Resuscitation is Mandatory
The 2010 American Heart Association guidelines state that "without objective signs of irreversible death and in the absence of known advance directives declining resuscitative attempts, full resuscitation should be offered." 1 A verbal discussion without documentation does not constitute a "known advance directive." 1
Neonatal resuscitation has particularly high success rates when cardiac arrest results from treatable causes (hypoxia, hypovolemia, cardiovascular response to interventions), and continuous monitoring allows immediate detection and treatment. 1
Immediate Actions Required
Begin high-quality CPR immediately if the newborn is unresponsive with absent or abnormal breathing: 1
- Chest compressions: At least 100/minute, compressing at least one-third the anterior-posterior diameter of the chest (approximately 4 cm or 1.5 inches in infants) 1
- Use 2-finger technique for lone rescuers on the sternum just below the intermammary line 1
- Compression-ventilation ratio of 3:1 for newly born infants in the delivery room setting, with pauses for ventilation 1
- Allow complete chest recoil after each compression and minimize interruptions 1
Provide positive-pressure ventilation with supplementary oxygen whenever indicated for neonatal resuscitation. 1, 2
Establish vascular access early (intravenous or intraosseous) for medication administration if needed. 1
Critical Pitfall to Avoid
Never perform "slow codes" or token resuscitative efforts. The practice of knowingly providing ineffective resuscitation is ethically inappropriate, compromises provider integrity, and creates false impressions. 1 Either provide full, high-quality resuscitation or have valid documentation to withhold it—there is no middle ground. 1
After Stabilization
Once the infant is stabilized (or if resuscitation is unsuccessful), immediately complete proper DNR documentation through discussion with the family and appropriate physician orders. 1 This ensures clarity for any future events and respects the family's previously expressed wishes through proper legal channels. 1
The DNR order must be completed, signed, and dated by the physician after documented discussion with the parents or legal representatives to avoid this situation recurring. 1