A. Qualified health care personnel shall
comply with the following general procedures and published Virginia Durable DNR
Order Implementation Protocols when caring for a patient who is in cardiac or
respiratory arrest and who is known or suspected to have a Durable DNR Order in
effect.
B. Initial assessment and
intervention. Perform routine
patient assessment and resuscitation or
intervention until a valid Durable DNR Order, Alternate DNR jewelry, or Other
DNR Order can be confirmed, as follows:
1.
Determine the presence of a Durable DNR Order, approved Alternate Durable DNR
jewelry, or Other DNR Order.
2. If
the
patient is within a qualified health care
facility or in transit between
qualified health care facilities, any qualified health care personnel may honor
an Other DNR Order as set forth in
12VAC5-66-60.
3. Determine that the Durable DNR form or
Alternate DNR jewelry is not altered.
4. Verify, through driver's license or other
identification with photograph and signature or by positive identification by a
family member or other person who knows the patient, that the patient in
question is the one for whom the Durable DNR Order, Alternate DNR jewelry, or
Other DNR Order was issued.
5. If
the Durable DNR Order, Alternate DNR jewelry, or Other DNR Order is intact,
unaltered, and verified as issued for the patient, qualified health care
personnel may consider it valid.
C. Resuscitative measures to be withheld or
withdrawn. In the event of cardiac or respiratory arrest of a
patient with a
valid Durable DNR Order, Alternate Durable DNR jewelry, or Other DNR Order
under the criteria set forth in subsection B of this section, qualified health
care personnel shall withhold or withdraw cardiopulmonary resuscitation (CPR)
unless otherwise directed by a physician physically present at the
patient
location. CPR shall include:
1. Cardiac
compression;
2. Artificial
ventilation;
3.
Defibrillation;
4. Endotracheal
Intubation or other advanced airway management including supra-glottic devices
such as the LMA, or other airway devices that pass beyond the oral pharynx,
such as the Combi Tube, PTL etc.; or
5. Administration of related procedures or
cardiac resuscitation medications as prescribed by the patient's physician or
medical protocols.
D.
Procedures to provide comfort care or to alleviate pain. In order to provide
comfort care or to alleviate pain for a
patient with a valid Durable DNR Order
of any type or Other DNR Order the following interventions may be provided,
depending on the needs of the particular
patient:
1. Airway management, including positioning,
nasal or pharyngeal airway placement;
2. Suctioning;
3. Supplemental oxygen delivery
devices;
4. Pain medications or
intravenous fluids;
5. Bleeding
control;
6. Patient positioning;
or
7. Other therapies deemed
necessary to provide comfort care or to alleviate pain.
E. Revocation.
1. If a
patient is able to, and does, express
to a health care provider or practitioner the desire to be resuscitated in the
event of cardiac or respiratory arrest, such expression shall revoke the
provider's or practitioner's authority to follow a Durable DNR Order or Other
DNR Order. In no case shall any person other than the
patient have authority to
revoke a Durable DNR Order or Other DNR Order executed upon the request of and
with the consent of the
patient himself.
If the patient is a minor or is otherwise incapable of
making an informed decision and the Durable DNR Order or Other DNR Order was
issued upon the request and with the consent of the person authorized to
consent on the patient's behalf, then the expression by said person to a health
care provider or practitioner of the desire that the patient be resuscitated
shall so revoke the provider's or practitioner's authority to follow a Durable
DNR Order or Other DNR Order.
2. The expression of such desire to be
resuscitated prior to cardiac or respiratory arrest shall constitute revocation
of the order; however, a new order may be issued upon consent of the patient or
the person authorized to consent on the patient's behalf.
3. The provisions of this section shall not
authorize any qualified emergency medical services personnel or licensed health
care provider or practitioner who is attending the patient at the time of
cardiac or respiratory arrest to provide, continue, withhold or withdraw
treatment if such provider or practitioner knows that taking such action is
protested by the patient incapable of making an informed decision. No person
shall authorize providing, continuing, withholding or withdrawing treatment
pursuant to this section that such person knows, or upon reasonable inquiry
ought to know, is contrary to the religious beliefs or basic values of a
patient incapable of making an informed decision or the wishes of such patient
fairly expressed when the patient was capable of making an informed
decision.
F.
Documentation. When following a
Durable DNR Order or Other DNR Order for a
particular
patient admitted to a qualified health care
facility, qualified
health care personnel shall document care rendered or withheld as required by
facility policies and procedures. When following a Durable DNR Order or Other
DNR Order for a particular patient who is not admitted to a qualified health
care
facility or who is in transit from a health care
facility, qualified
health care personnel shall document in the patient's medical record the care
rendered or withheld in the following manner:
1. Use standard patient care reporting
documents (i.e. patient chart, pre-hospital patient care report).
2. Describe assessment of patient's cardiac
or respiratory arrest status.
3.
Document which identification (Durable DNR Order, Alternate Durable DNR
jewelry, or Other DNR Order or alternate form of identification) was used to
confirm Durable DNR status and that it was intact, not altered, not canceled or
not officially revoked.
4. Record
the name of the patient's physician who issued the Durable DNR Order, or Other
DNR Order.
5. If the patient is
being transported, keep the Durable DNR Order, Alternate Durable DNR jewelry,
or Other DNR Order with the patient.
G. General considerations. The following
general principles shall apply to implementation of all Durable DNR Orders.
1. If there is misunderstanding with family
members or others present at the patient's location or if there are other
concerns about following the Durable DNR Order or Other DNR Order, contact the
patient's physician or EMS medical control for guidance.
2. If there is any question about the
validity of a Durable DNR Order, resuscitative measures should be administered
until the validity of the Durable DNR Order or Other DNR Order is
established.