Essential Components of DNR/DNI Consent Forms

Patient Information and Capacity

• A DNR/DNI order should include a clear statement of the patient's capacity at the time of decision-making, as well as the date of DNR/DNI order implementation, according to the American Society of Anesthesiologists 1

Specific Interventions to be Withheld

• The order should include specific instructions about which interventions are to be withheld, such as endotracheal intubation and mechanical ventilation, as recommended by the American Society of Anesthesiologists 1
• Vasopressors should be explicitly stated as an intervention to be withheld, as per the American Heart Association 2

Interventions Still Permitted

• A statement should clarify that DNR/DNI orders do not affect other treatments unless specifically noted, as stated by the American Heart Association 2
• Supplemental oxygen, intravenous fluids, pain management, antibiotics, and other comfort measures may continue, as applicable, according to the American Society of Anesthesiologists 1

Documentation of Discussion

• A record of discussion with the patient and/or surrogate decision-maker should be documented, including the patient's values, goals, and preferences, as recommended by the European Society for Medical Oncology 3

Signatures and Verification

• The patient's signature (if capable) and surrogate decision-maker signature (if patient lacks capacity) should be included, as well as witness signatures, according to the American Society of Anesthesiologists 1 and the European Society for Medical Oncology 3

Review and Renewal Information

• The order should include a statement indicating when it should be reviewed, such as with significant change in condition, and a process for revoking or modifying the order, as recommended by the American Society of Anesthesiologists 1

Important Considerations for DNR/DNI Forms

Legal Requirements

• Forms must explicitly state they apply even when life is at risk and must be written, witnessed, and clearly state applicability to life-sustaining treatment, according to the American Society of Anesthesiologists 1

Scope Clarification

• A clear statement should be included that DNR/DNI orders are not advance directives but specific medical orders, as stated by the American Society of Anesthesiologists 1 and the European Society for Medical Oncology 3
• The order should explain that DNR/DNI status does not limit other appropriate treatments, as per the American Heart Association 2
• The order can be suspended for procedures when appropriate, as recommended by the American Heart Association 2

Do Not Resuscitate Orders in Florida

Legal Framework for DNR Orders

• The American Heart Association guidelines explicitly state that a licensed physician's order is necessary to withhold CPR in the hospital setting 4
• DNR orders must be completed, signed, and dated by a physician after a documented discussion with the patient and/or family or legal representative 5
• DNR orders (also called DNAR - Do Not Attempt Resuscitation, or AND - Allow Natural Death) are legal orders written either in the patient's file or on a legal form to respect the wishes of a patient not to undergo CPR 6, 7

Requirements for Valid DNR Documentation

• DNR orders should clearly state either full resuscitation or no attempt at resuscitation 5
• Oral DNR orders are not acceptable - they must be written 4
• The order should provide explicit instructions for specific emergency interventions that may arise 4
• Documentation must include the rationale for the DNR order and discussions with the patient, surrogate, and family 4

Scope of DNR Orders

• A DNR order does not automatically preclude other interventions such as administration of parenteral fluids, nutrition, oxygen, analgesia, sedation, antiarrhythmics, or vasopressors 4
• DNR orders should specify which interventions are to be withheld 4
• DNR orders carry no implications about other forms of treatment, and other aspects of the treatment plan should be documented separately 4

Best Practices for DNR Documentation

• DNR orders should be reviewed periodically as per local protocol, particularly if the patient's condition changes 4
• DNR orders should also be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate 4

Common Pitfalls to Avoid

• Lack of clarity in limitation of resuscitation orders can complicate care, especially for patients with special healthcare needs 8

DNR/DNE Consent Model Guidelines

Special Considerations

• For perioperative care, the American Society of Anesthesiologists clarifies that DNR/DNE orders may remain in effect during surgery, depending on the patient's wishes and medical condition 9
• The American Academy of Pediatrics states that for patients with developmental disabilities or in foster care, the same ethical principles apply as for other patients, ensuring their autonomy and dignity in end-of-life care decisions 10

Conflict Resolution and Palliative Care

• The American Academy of Pediatrics recommends that when conflicts arise between healthcare providers and patients/families regarding DNR/DNE decisions, basic principles of negotiation and conflict resolution should be employed, with support from spiritual care providers and consultants in palliative care or ethics 10
• The American Heart Association recommends aggressive care early after certain conditions, like intracerebral hemorrhage, and postponement of new DNR orders until at least the second full day of hospitalization, to ensure optimal patient outcomes 11

DNR Orders and Patient Care

Introduction to DNR Orders

• The American Academy of Pediatrics recommends that DNR decisions are ethically supportable when the burdens of treatment outweigh the benefits to the patient 12
• A DNR order means "do not attempt resuscitation" when the heart or breathing stops, while clarifying that all other appropriate medical care and comfort measures will continue unless specifically refused, as suggested by the American Academy of Pediatrics 12

Communication and Decision-Making

• Having a support person present, such as a nurse, chaplain, or social worker, can assist the family during difficult conversations about DNR orders, according to the Society of Critical Care Medicine 13, 14
• The American Academy of Pediatrics suggests that in rare circumstances of extreme burden of treatment with no benefit beyond postponing death, it may be ethically supportable to forgo life-sustaining treatment without family agreement, after exhausting conflict resolution strategies and obtaining ethics consultation 12

Special Considerations

• The American Academy of Pediatrics recommends that DNR orders may remain in effect during surgery if consistent with the patient's goals of care, and should be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate 12
• In cases where family disagrees with the medical team, the American Academy of Pediatrics suggests that ethics consultation should be obtained to resolve conflicts and determine the best course of action 12

DNR Orders Without DNI

Introduction to DNR and DNI

• A patient can have a Do Not Resuscitate (DNR) order without a Do Not Intubate (DNI) order, as these are separate medical decisions that should be documented independently, according to the American Heart Association 15
• DNR specifically means no chest compressions or defibrillation will be performed if the patient experiences cardiac arrest, as stated by the American Heart Association 15
• DNI specifically means no endotracheal intubation will be performed, which applies to multiple situations beyond cardiac arrest, such as respiratory failure, airway protection, and surgical procedures, as noted by the American College of Cardiology 16
• Some patients may choose to accept defibrillation and chest compressions but not intubation and mechanical ventilation, which is a valid and ethically appropriate choice, according to the American Heart Association 15

Documentation and Implementation

• When writing DNR orders without DNI, explicit, separate orders for each limitation must be written, and oral orders are never acceptable, as recommended by the American Heart Association 15
• The rationale for the DNR order and discussions with the patient, surrogate, and family must be documented, according to the American Heart Association 15
• It must be clarified that DNR does not automatically preclude intubation, mechanical ventilation, vasopressors, oxygen, IV fluids, antibiotics, or other interventions unless specifically included in the order, as stated by the American College of Cardiology 16 and the American Heart Association 15

Clinical Implications

• A patient with DNR but no DNI order should receive full respiratory support, including intubation and mechanical ventilation for respiratory failure, airway protection, or other non-arrest indications, as recommended by the American College of Cardiology 16
• The patient should receive all appropriate medical interventions, such as vasopressors, oxygen support, electrolyte replacement, IV fluids, pain management, and antibiotics, according to the American College of Cardiology 16 and the American Heart Association 15
• No chest compressions or defibrillation should be performed if cardiac arrest occurs, as stated by the American Heart Association 15

Review and Revision of Orders

• DNR orders without DNI should be reviewed periodically as per local protocol, particularly if the patient's condition changes, as recommended by the American Heart Association 15
• These orders should be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate to determine applicability in the operating suite, according to the American Heart Association 15
• DNR/DNI status can be suspended for procedures when appropriate after discussion with the patient, as noted by the American College of Cardiology 16