What is the responsibility regarding a Do Not Resuscitate (DNR) order for a young patient with muscular dystrophy transferred to a tertiary hospital without the team's knowledge of the pre-existing DNR order?

Identifying a DNR Order is the Medical Team's Responsibility

The correct answer is D: Identifying a DNR is a duty of one of the members of the medical team. When a patient is transferred between hospitals, the receiving medical team must continue resuscitation efforts already initiated until they properly verify and document any pre-existing DNR order, placing the burden of discovery and verification squarely on the medical team 1.

Why the Medical Team Bears This Responsibility

DNR orders from other facilities do not automatically transfer to the receiving hospital. 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 means:

• The receiving hospital's medical team must continue ongoing resuscitation efforts until proper verification occurs 1
• A licensed physician's order is necessary to withhold CPR in the hospital setting, and this order must be written in accordance with local policy in the patient's chart 2
• Oral DNR orders are explicitly unacceptable 1, 2

The Verification Process

The medical team must follow a specific sequence when discovering a potential DNR order from another facility:

1. Continue treatment - Do not stop resuscitative efforts based solely on discovering a DNR order from another facility 1
2. Contact the family immediately to verify the existence and current validity of the DNR order 1
3. Obtain new documentation from the attending physician at the receiving facility 1
4. Document thoroughly all conversations with the family, including whether their wishes regarding resuscitation have changed 1
5. Then modify care accordingly only after completing the above steps 1

Why the Other Options Are Incorrect

Option A is incorrect because while DNR orders are institution-specific medical orders that must be rewritten 2, the patient's wishes documented in advance directives should inform the new DNR order at the receiving facility 2. The issue is not that DNRs are "invalid" but that they require proper verification and new documentation.

Option B is incorrect because there is no 24-hour validity period for DNR orders between hospitals. The order must be verified and rewritten according to the receiving institution's protocols regardless of timing 2.

Option C is incorrect because the responsibility lies with the medical team, not the family. While the family should be contacted for verification 1, the burden of discovery and proper documentation rests with healthcare providers.

Special Considerations for Muscular Dystrophy Patients

This case involves additional urgency because patients with muscular dystrophy and compromised respiratory function can deteriorate rapidly during intercurrent illness. 1 Therefore:

• An individualized emergency healthcare plan should be in place and discussed with the patient and family 1
• 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 1
• End-of-life directives must be clearly documented and available for use in the case of an emergency for patients with Duchenne muscular dystrophy 3

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.

The referring physician should ideally identify and communicate critical information, including DNR status, to the receiving physician before transfer occurs 1, but when this fails (as in this scenario), the receiving team must actively seek this information rather than assuming the family or patient will volunteer it.