What is the immediate course of action for a 15-month-old pediatric patient in the Emergency Room (ER) when a Do Not Resuscitate (DNR) order is discovered after treatment has started?

DNR Order Management When Discovered After Treatment Initiation in the Emergency Room

Continue the treatment already initiated while immediately verifying the DNR order with the family, as DNR orders from other facilities require proper verification and documentation at the receiving facility before they can be honored. 1

Immediate Actions Required

Do not stop ongoing resuscitative efforts based solely on discovering a DNR order from another facility. 1 The American Heart Association guidelines emphasize that treatment already initiated should continue until proper verification and documentation occurs. 1

Key Steps in Sequential Order:

1. Continue current treatment - Maintain all resuscitative measures already in progress 1

2. Contact the family immediately to verify:

   • The existence and current validity of the DNR order 1, 2
   • Whether their wishes regarding resuscitation have changed, as family understanding and wishes may evolve over time 2
   • The specific scope of interventions they wish to withhold 1

3. Document thoroughly in the medical record:

   • The conversation with the family 1
   • Any discussions about changes in resuscitation wishes 1
   • The rationale for continuing or modifying treatment 2

Critical Documentation Requirements

The American Heart Association explicitly states that oral DNR orders are unacceptable - the attending physician must write a new DNR order in accordance with local policy in the patient's chart. 1 This new order must include:

• A note explaining the rationale for the DNR order 1
• Documentation of discussions with the patient's family 1
• Specific instructions about which interventions are to be withheld and which should continue 1

Why DNR Orders from Other Facilities Cannot Be Automatically Honored

Regulations regarding out-of-hospital and inter-facility DNR orders vary significantly from state to state, and a separate order must be written for different healthcare settings. 1, 3 DNR orders are not permanent lifetime orders and require re-evaluation when:

• The patient's condition changes 1, 2
• The patient transfers to a new facility 1
• Before any surgical or procedural intervention 2

Important Scope Clarifications

A DNR order does not automatically preclude other interventions such as:

• Parenteral fluids 1
• Nutrition 1
• Oxygen 1
• Analgesia 1
• Sedation 1
• Antiarrhythmics 1
• Vasopressors 1

These interventions should continue unless specifically included in the limitation-of-treatment order. 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 This is emphasized by both the American Heart Association and the American Academy of Pediatrics. 1

Additional pitfalls include:

• Treating DNR orders as permanent directives rather than medical orders requiring active review 2
• Stopping all medical interventions when only CPR is meant to be withheld 1
• Failing to document the verification process and family discussions 1

Answer to the Multiple Choice Question

The correct answer is C: DNR needs to be verified by family. 1 While treatment continues, immediate family contact for verification is the essential next step, as DNR orders from other facilities require re-evaluation and new documentation at the receiving facility before they can be honored. 1