Responsibility for Identifying DNR Orders During Patient Transfer
Identifying a DNR order is a duty of one of the members of the medical team (Answer D). The receiving medical team has the professional and ethical responsibility to verify the patient's resuscitation status upon transfer, not the parents.
Professional Duty of the Medical Team
The American Heart Association explicitly states that physicians should initiate discussions about CPR with all patients admitted for medical and surgical care, and a licensed physician's order is necessary to withhold CPR in the hospital setting 1. This professional obligation extends to the receiving team during transfers.
- The attending physician must write the DNR order in accordance with local policy in the patient's chart, with documentation of discussions with the patient, surrogate, and family 1
- Oral DNR orders are never acceptable - they must be written and properly documented 1
- The medical team must actively verify resuscitation status as part of standard admission procedures, particularly for patients with chronic progressive conditions like muscular dystrophy 1
Why DNR Orders Remain Valid Across Transfers
DNR orders do not automatically expire when transferring between hospitals (making options A and B incorrect). However, the receiving team must identify and verify the order:
- DNR orders should be reviewed periodically as per local protocol, particularly if the patient's condition changes or during transfers 1, 2
- The order remains ethically and legally valid but requires documentation in the new facility's medical record system 1
- Transfer between healthcare settings requires re-evaluation and new documentation of DNR orders to ensure continuity of care 2
Why Parents Are Not Primarily Responsible
While parents are integral members of the healthcare team and participate in shared decision-making, the professional duty to identify existing DNR orders falls on the medical team (making option C incorrect):
- Parents and family caregivers are recognized as best able to appreciate the best interests of the child and participate in developing the healthcare plan 1
- However, physicians have the ethical duty of veracity and fidelity to share complete information and identify existing orders 1
- The care of children with medical complexity involves contributions from multiple specialists, all of whom share responsibility for knowing the patient's code status 1
Critical Pitfalls to Avoid
Assuming no DNR exists without verification is dangerous. The receiving team should:
- Immediately review transfer documentation for any advance directives or DNR orders 1
- Contact the transferring facility if documentation is unclear or missing 1
- Communicate directly with parents/guardians to verify resuscitation preferences while simultaneously reviewing medical records 1
- Document the verification process in the medical record, including when and how DNR status was confirmed 1
In this scenario, the team began resuscitation appropriately given the lack of immediate knowledge about the DNR order, as CPR is initiated based on implied consent for emergency treatment in the absence of a known DNR order 1. However, the system failure was in the transfer process - the receiving team should have had mechanisms to identify the DNR order before the emergency occurred 3.
Best Practice for Transfers
Standardized transfer protocols should include:
- Explicit documentation of DNR status in transfer paperwork 1
- Direct communication between transferring and receiving physicians about code status 1
- Immediate review of advance directives upon patient arrival 1
- Color-coded identification systems (though these vary by institution and pose risks if not standardized) 3
The medical team's responsibility includes not only identifying existing DNR orders but also ensuring proper documentation and communication with the family about the patient's goals of care in the new setting 1.