DNR Verification in the Emergency Department
When a 15-month-old child presents to the emergency department and treatment has already been initiated before discovering a DNR order from another facility, the DNR must be verified with the family before being honored. The correct answer is C.
Rationale for Family Verification
The American Heart Association guidelines explicitly state that care of children with special healthcare needs is "often complicated by a lack of medical information, a comprehensive plan of medical care, a list of current medications, and lack of clarity in limitation of resuscitation orders such as 'Do Not Attempt Resuscitation (DNAR)' or 'Allow Natural Death (AND)'" 1. This inherent complexity necessitates direct verification.
Key principles supporting family verification:
Out-of-hospital DNR orders require specific documentation: The physician must write a separate order specifically for the out-of-hospital setting, and regulations regarding out-of-hospital DNAR directives vary from state to state 1.
Parents and caregivers should maintain accessible copies: Parents and child-care providers are encouraged to keep copies of medical information at home, with the child, and at the child's school or child-care facility 1.
Emergency Information Forms should be available: The American Academy of Pediatrics and American College of Emergency Physicians developed standardized Emergency Information Forms that should accompany children with complex medical needs, and the school or primary caretaker should have copies of DNAR orders 1.
Why Other Options Are Incorrect
Option A (DNR from other facilities are not acceptable) is incorrect because DNR orders from other facilities can be honored, but they require proper verification 1. The issue is not blanket rejection but rather ensuring the order is current, valid, and reflects the family's current wishes.
Option B (DNR from other facilities are not acceptable after 24 hours) has no basis in the American Heart Association guidelines or standard practice 1. There is no arbitrary time limit for DNR validity based solely on elapsed time.
Option D (DNR needs to be verified by team member) is insufficient because team member verification alone does not address the fundamental need to confirm current family wishes and ensure the order reflects the patient's current clinical context 1.
Critical Clinical Considerations
When treatment has already been initiated:
- Continue stabilization efforts while attempting to reach the family for verification 1.
- The presumption to resuscitate remains reasonable when no information is immediately available about the patient's or surrogate's wishes 2.
- Promptly and actively seek to clarify the family's current wishes rather than relying on presumed consent 2.
Common pitfalls to avoid:
- Do not assume a DNR order from another facility automatically applies without verification, as family wishes may have changed or the clinical context may differ 1.
- Do not delay life-saving interventions while searching for documentation if the child is actively deteriorating and family cannot be immediately reached 1.
- Recognize that unilateral DNAR orders without parental approval carry significant ethical and legal risks, particularly in pediatrics where parental authority is paramount 3, 4.