As the numbers of medically fragile children attending schools increase, it is possible that you may have a student with a Do Not Resuscitate (DNR) or Do Not Attempt to Resuscitate order in place. DNR's in school can be a contentious issue and are always an emotional challenge. It is important for you to come to a personal comfort level with what is in the best interest of the child. As the health professional at the school, it is vital that you be an informed voice in the process.
Begin by reading this very thoughtful document from the American Academy of Pediatrics.
Much of the available information on end of life decisions is, understandably, written for adults. The Foundation for Healthy Communities has a series of excellent resources on the topic. In particular review the "Master Education Document", "Portable Do Not Attempt Resuscitation Form - Q&A", and "DNR Identification Jewelry."
Here are some basic steps to help you deal with the situation if a child in your school has a DNR.
- Start by meeting with the parents or guardians and look over the DNR together. You should be provided your own copy. The DNR order may outline specifically what is and is not allowed (for example, no CPR, advanced airways, ventilation or defibrillation.) If not, you can clarify this in writing with the parent or guardian. Generally speaking; suctioning the airway, providing oxygen, and "first aid" type interventions such as splinting and bleeding control should be performed. Some interventions will vary from one situation to the next, for example, should you start an IV? Should you call EMS?
- You will need to draft an individualized health plan ("IHP") for the student in question. Try to involve parents, teachers, administration, local EMS, the ordering physician and the student (if appropriate) in developing the plan. The IHP must include an emergency care plan to help other staff know exactly how to handle a medical emergency.
- Your school should develop a DNR policy if they have not yet done so. The policy should be drafted to limit the trauma to staff and other students as well as to respect the wishes of the families impacted. You should get support from administration, parents, EMS, teachers and the school's lawyer in developing your policy and procedures. The policy should establish a protocol for the following:
- Verifying the DNR order with the physician
- Ensuring the student's IHP addresses mortuary arrangements and transport
- Ensuring the student's IHP specifically outlines what actions may and may not be performed
- Ensuring the student's IHP addresses protocol for notifying family of the death
- Notification of EMS and Medical Examiner that student has a DNR order when they enroll (requires written consent from parents)
- Plan of support for staff and students after the death
- Plans for where the body will be kept
- Pronouncing the death
Please note: If an ambulance is called, EMS workers will only withhold CPR from a child in cardiac or respiratory arrest if they are presented with a complete DNR form or if the child is wearing the official DNR identification jewelry. Saf-C 5922.02 is the administrative rule from the Department of Safety Bureau of Emergency Medical Services that deals with DNR orders and EMS personnel.
As always, you should work closely with your school's administration and legal counsel on any and all issues that arise.
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