DNR Order Management When Discovered After Treatment Initiation
When a DNR order from another facility is discovered after treatment has already begun in the ER, you must verify the DNR order with the family before making any changes to the current treatment plan. 1
Immediate Actions Required
Continue Current Treatment
- Do not stop ongoing resuscitative efforts based solely on discovering a DNR order from another facility. 1
- Treatment already initiated should continue until proper verification and documentation occurs. 1
- The American Heart Association guidelines emphasize that DNR orders must be properly documented in the current facility's medical record by the attending physician, with oral DNR orders being explicitly unacceptable. 1
Verify DNR Status With Family
- Contact the family immediately to verify the existence and current validity of the DNR order. 1
- Discuss with the family whether their wishes regarding resuscitation have changed, as the American Academy of Pediatrics emphasizes that family understanding and wishes may evolve over time. 2
- Document this conversation thoroughly in the medical record. 1
Critical Considerations for Pediatric DNR Orders
DNR Orders Are Not Permanent
- The American Heart Association explicitly states that DNR orders should be reviewed periodically as per local protocol, particularly when the patient's condition changes, as they are not permanent lifetime orders. 2
- DNR orders from other facilities require re-evaluation and new documentation at the receiving facility. 1
State-Specific Regulations
- Regulations regarding out-of-hospital and inter-facility DNR orders vary significantly from state to state. 1
- A separate order must be written for different healthcare settings. 1
Scope of DNR Orders
- A DNR order does not automatically preclude other interventions such as parenteral fluids, nutrition, oxygen, analgesia, sedation, antiarrhythmics, or vasopressors unless these are specifically included in the order. 1
- The limitation-of-treatment order should provide explicit instructions for specific emergency interventions. 1
Documentation Requirements
Once family verification occurs and DNR status is confirmed:
- The attending physician must write a new DNR order in accordance with local policy in the patient's chart. 1
- Include a note explaining the rationale for the DNR order, other specific limitations of care, and document discussions with the patient's family. 1
- Specify which interventions are to be withheld and which should continue. 1
Common Pitfalls to Avoid
- Never assume a DNR order from another facility is automatically valid at your institution without proper verification and documentation. 1
- Do not interpret lack of documentation as permission to withhold all care—DNR orders are specific to cardiopulmonary resuscitation attempts. 1
- Avoid making assumptions about family wishes without direct communication, as circumstances and preferences may have changed. 2
The correct answer is C: DNR needs to be verified by family.