DNR Order Review in Pediatric Patients
B- DNR is reviewed based on patient's condition is the correct next step for the physician managing this pediatric DNR order. 1
Why DNR Orders Require Ongoing Review
DNR orders are not permanent lifetime directives and must be actively reviewed and maintained through physician documentation, particularly when the patient's clinical condition changes. 1 The American Heart Association explicitly states that these orders should be reviewed periodically as per local protocol and are not "valid for life." 1
Specific Review Triggers for Pediatric DNR Orders
The physician should review this child's DNR order when any of the following occur:
- Significant changes in clinical condition (either improvement or deterioration) 1
- Before any surgical or procedural intervention 1, 2
- When family understanding or wishes may have evolved 1
- At regular intervals per institutional protocol based on clinical need 1
Required Documentation at Each Review
Each review must include: 1
- Documented discussion with family/surrogate decision-makers about current clinical status and goals
- Clear notation of the rationale for continuing, modifying, or revoking the DNR order
- Specific instructions about which interventions are withheld and which continue
Why the Other Options Are Incorrect
Option A (DNR valid for life) is explicitly contradicted by American Heart Association guidelines, which state DNR orders are medical orders that must be actively maintained, not permanent directives. 1
Option C (annual review by primary consultant) is too rigid and does not reflect guideline recommendations, which emphasize review based on clinical changes rather than arbitrary time intervals. 1
Option D (3-month review for pediatric age) has no support in published guidelines. While more frequent review may be appropriate for children given their potential for developmental changes, the trigger should be clinical condition changes, not a fixed 3-month schedule. 1
Critical Pitfall to Avoid
Never assume DNR orders are permanent or "set and forget" orders. 1 The American Academy of Pediatrics emphasizes that ongoing communication with families is critical, as their understanding and wishes may evolve over time, particularly in pediatric cases where prognosis and developmental trajectory may be uncertain. 1
Practical Implementation
For this child with white matter disease and permanent brain damage, the physician should: 1
- Establish a review schedule tied to clinical milestones (hospitalizations, infections, developmental assessments)
- Document each review with updated family discussions
- Clarify which interventions continue (comfort measures, antibiotics, oxygen) versus which are withheld (chest compressions, defibrillation, intubation)
- Ensure the order transfers appropriately between care settings (home, school, hospital), as regulations vary by state and setting 3, 1