Honoring Do-Not-Attempt-Resuscitation Requests in Schools

Abstract

Increasingly, children and adolescents with complex chronic conditions are living in the community. Federal legislation and regulations facilitate their participation in school. Some of these children and adolescents and their families may wish to forego life-sustaining medical treatment, including cardiopulmonary resuscitation, because they would be ineffective or because the risks outweigh the benefits. Honoring these requests in the school environment is complex because of the limited availability of school nurses and the frequent lack of supporting state legislation and regulations. Understanding and collaboration on the part of all parties is essential. Pediatricians have an important role in helping school nurses incorporate a specific action plan into the student's individualized health care plan. The action plan should include both communication and comfort-care plans. Pediatricians who work directly with schools can also help implement policies, and professional organizations can advocate for regulations and legislation that enable students and their families to effectuate their preferences. Pediatrics 2010;125:1073-1077 INTRODUCTIONIn a groundbreaking statement in 1974, the American Heart Association declared that cardiopulmonary resuscitation (CPR) is not indicated for all patients. Cases of terminal, irreversible illness in which death is an expected outcome do not necessarily merit CPR. 1 Do-notresuscitate (DNR) orders developed out of efforts to identify patients who do not wish to receive CPR. The terminology eventually changed to "do not attempt resuscitation" (DNAR), acknowledging that resuscitation is not always successful. Some contemporary authors have proposed replacing the term "DNAR" with "allow natural death" (AND) to indicate the positive goal. DNAR orders are physician orders, in contrast to patient directives. In 1994, the American Academy of Pediatrics (AAP) issued guidelines on foregoing life-sustaining medical treatment, including CPR, for children and adolescents. 2 The AAP believes it is ethically acceptable to forego CPR when it is unlikely to be effective or when the risks outweigh the benefits, including the parents' and child's assessment of the child's quality of life.DNAR orders are not orders to "do nothing," nor do they represent a decrease in the quality or intensity of care. DNAR orders should be implemented in the context of palliative care, including plans for managing pain and other symptoms, as well as addressing emotional and spiritual needs.