Management of DNR Orders in Pediatric Resuscitation Situations
Direct Answer
Continue resuscitation immediately while simultaneously verifying the DNR order with the mother and obtaining proper documentation from the hospital physician—treatment already initiated must continue until proper verification and documentation occurs. 1, 2
Immediate Actions Required
The medical team must take the following sequential steps:
- Continue ongoing resuscitative efforts without interruption based solely on the mother's verbal report of a DNR order 1, 2
- Contact the mother immediately to verify the existence, current validity, and specific details of the DNR order 1, 2
- Obtain new documentation from the attending physician at the receiving hospital, as oral DNR orders are explicitly unacceptable 1, 2
- Document all conversations with the mother thoroughly, including whether her wishes regarding resuscitation have changed 1, 2
Why This Approach Is Critical
DNR orders do not automatically transfer between settings or facilities. 1, 2 The American Heart Association explicitly states that treatment already initiated should continue until proper verification and documentation occurs, placing the burden of discovery and verification squarely on the medical team. 1
The attending physician at the current hospital must write a new DNR order in accordance with local policy in the patient's chart, including a note explaining the rationale and documenting discussions with the family. 2
Verification Process
When verifying the DNR order with the mother:
- Confirm the DNR order exists and was properly documented at another facility 1, 2
- Determine if the mother's wishes have changed given the current clinical situation 1, 2
- Clarify which specific interventions should be withheld versus continued, as DNR does not automatically preclude oxygen, fluids, antibiotics, or other supportive measures 2
- Review whether the DNR order was intended for the out-of-hospital setting, as regulations vary significantly by state and setting 3, 2
Documentation Requirements
The hospital physician must:
- Write a new DNR order clearly detailing the limits of any attempted resuscitation 3
- Document the rationale for the DNR order in the medical record 2
- Specify which interventions are to be withheld and which should continue 2
- Ensure the order is completed, signed, and dated after documented discussion with the mother 3
Special Considerations for This Child
Given the child's muscle atrophy disease and recurrent chest infections:
- This child likely has neuromuscular disease with compromised respiratory function and can deteriorate rapidly during intercurrent illness 4
- An individualized emergency healthcare plan should have been in place and discussed with the family 1
- Contact the child's primary respiratory and neuromuscular teams as soon as practicable 1, 4
- Recurrent chest infections indicate loss of respiratory muscle strength, ineffective cough, or silent aspiration 4
Critical Pitfalls to Avoid
Never assume a DNR order from another facility or setting is automatically valid without proper verification and documentation at your institution. 1, 2
Do not stop resuscitative efforts based solely on discovering a DNR order from another facility or on verbal report from family—instead follow the proper sequence: continue treatment → verify with family → obtain new physician documentation → then modify care accordingly. 1, 2
DNR orders are not permanent lifetime orders and should be reviewed periodically, particularly when the patient's condition changes. 2
Answer to the Multiple Choice Question
The correct answer is C) Take the order by hospital physician to carry out resuscitation. The hospital physician must write new orders based on proper verification and documentation, not simply accept verbal reports or orders from other facilities. 1, 2 However, this should occur simultaneously with ongoing resuscitation efforts and family verification, not as a unilateral decision to override the mother's stated wishes without proper investigation. 3, 1, 2