Responsibility for Identifying DNR Orders During Inter-Hospital Transfer
D) Identifying a DNR is a duty of one of the members of the medical team 1.
Why the Medical Team Bears This Responsibility
When a patient is transferred between hospitals and resuscitation begins without knowledge of a pre-existing DNR order, the medical team—not the parents or family—has the primary duty to identify and verify the DNR status. The American Heart Association explicitly states that treatment already initiated should continue until proper verification and documentation of a DNR order from another facility occurs 1. This places the burden of discovery and verification squarely on the medical team.
Key Principles for the Medical Team
DNR orders from other facilities do not automatically transfer 1. The receiving hospital's medical team must:
- Continue ongoing resuscitation efforts until proper verification occurs 1
- Contact the family immediately to verify the existence and current validity of the DNR order 1
- Obtain new documentation from the attending physician at the receiving facility, as oral DNR orders are explicitly unacceptable 1
- Document all conversations with the family thoroughly, including whether their wishes regarding resuscitation have changed 1
Why Options A and B Are Incorrect
DNR orders are not automatically invalid between hospitals, but they require re-evaluation and new documentation at the receiving facility 1, 2. There is no 24-hour grace period or automatic invalidation—rather, the order must be properly verified and re-written by the receiving facility's attending physician according to local policy 1.
Why Option C Is Incorrect
While family input is critical, the duty to identify the DNR order belongs to the medical team, not the parents 1. The American Heart Association guidelines emphasize that the attending physician must write a new DNR order with proper documentation after discussion with the family 1. The family's role is to verify and confirm their wishes, but the systematic responsibility for discovering and documenting the DNR status rests with healthcare providers.
Critical Pitfalls to Avoid
Never assume a DNR order from another facility is automatically valid without proper verification and documentation 1. This is emphasized by both the American Heart Association and the American Academy of Pediatrics 1.
Do not stop resuscitative efforts based solely on discovering a DNR order from another facility 1. The proper sequence is: continue treatment → verify with family → obtain new physician documentation → then modify care accordingly.
Pre-Transfer Coordination Requirements
The referring physician should identify and communicate critical information including DNR status to the receiving physician before transfer occurs 3. A copy of the medical record should accompany the patient, though preparation of records should not delay urgent transport 3. When this communication breaks down—as in this scenario—the receiving team must actively seek this information.
Special Considerations for Muscular Dystrophy Patients
Patients with Duchenne muscular dystrophy and compromised respiratory function can deteriorate rapidly during intercurrent illness 3. An individualized emergency healthcare plan should be in place and discussed with the patient and family 3. However, when this information is not immediately available during transfer, the medical team must take active steps to obtain it while continuing appropriate care.
The medical team should contact the primary respiratory and neuromuscular teams from the referring facility as soon as practicable when a patient with muscular dystrophy is admitted with acute deterioration 3.