What is the immediate course of action for a 15-month-old pediatric patient who has begun receiving treatment in the Emergency Room (ER) and is subsequently found to have a Do Not Resuscitate (DNR) order?

What to Do When a DNR Order is Discovered After Treatment Has Started

The DNR order must be verified with the family or legal guardian before any decision to limit resuscitation is made, making option C the correct answer. 1, 2

Why Family Verification is Required

In the emergency department setting, DNR orders from outside facilities cannot be automatically honored without verification because:

• Emergency physicians have a heightened obligation to promptly address DNR status when appropriate decisions about resuscitation have been reached previously, but this requires confirmation that the order is clearly valid 1
• The decision-making process for DNR orders in emergency settings typically involves consultation with family members (occurring in 89% of cases), with a mean of 1.4 family members per patient involved in the discussion 2
• DNR orders can and should be written by ED physicians after consultation with the family, even when the setting is not ideal 2

The Critical Distinction for Pediatric Patients

For a 15-month-old infant, family involvement is absolutely essential because:

• The patient cannot participate in the decision-making process due to age and developmental stage 2
• Parents may have specific concerns about how a DNR order affects ongoing medical care, and these concerns must be addressed 3
• The emergency physician must verify that the DNR order reflects current family wishes and applies to the present clinical situation 1

Why the Other Options Are Incorrect

Option A (DNR from other facilities are not acceptable) is too absolute:

• DNR orders from other facilities can be honored, but only after proper verification 1
• A "clearly valid portable prehospital DNR order" should be promptly addressed by emergency physicians 1

Option B (DNR not acceptable after 24 hours) has no basis in guidelines:

• There is no time-based expiration for DNR orders in the literature provided 1, 2
• The validity depends on verification, not time elapsed 1

Option D (verification by team member) is insufficient:

• While team communication is important, family consultation is the standard of care 2
• The family must be involved in the decision-making process, not just internal team members 1, 2

Practical Approach in This Scenario

Once treatment has already been initiated, you should:

1. Continue current resuscitative efforts until the DNR status is clarified 1
2. Immediately contact the family to verify the DNR order and understand their current wishes 2
3. Obtain documentation of the original DNR order from the other facility 1
4. Discuss with the family whether the DNR order applies to the current clinical situation and whether they wish to continue, modify, or suspend it 4
5. Document the conversation and the family's wishes clearly in the medical record 4

Common Pitfall to Avoid

Do not assume that starting treatment invalidates the DNR or that you must continue all interventions:

• The fact that treatment was initiated before discovering the DNR does not obligate you to continue if the family confirms the DNR applies to the current situation 1
• However, you cannot unilaterally stop treatment without family verification of the DNR order 1, 2