The following outline attempts to summarize the ethical matters and those specifications that touch on ethical matters that the law (1998) and rules (1999) for the new DNR Comfort Care law contains. It does not address all the items contained in the law.

To view the DNR Comfort Care forms CLICK HERE, then click on "forms" and then on "DNR Comfort Care."
 
 

1. WHY IS DNR LINKED TO ETHICS RATHER THAN  BEING SIMPLY LEFT TO MEDICAL JUDGMENT?

DNR orders have a very important ethical component for the following reasons: 1. They are directly related to the dignity of patients particularly insofar as they involve the identification and honoring of patients' wishes. 2. They involve serious consideration of the patients' views of life and death and the goods that accompany them. 3. They incorporate the patient's exercise of autonomy or the appropriate exercise of proxy decision making through the process of informed consent. 4. They require careful attention to the principle of justice which holds that individuals are to be treated in accordance with their conditions. 5. They promote communication about end-of-life decisions between patient, caregivers, and proxies. 6. They open the door to important discussions about advance directives. 7. They can establish continuity of care for the patient.

 
 

2. HOW DOES THE DNR COMFORT CARE LAW ADDRESS THE ETHICAL ISSUES RAISED IN DNR ORDERS?

1. There is an expectation that there will be a process of communication between the caregiver and the patient or patient's proxy which will inform the patient/proxy in detail about the patient's condition and allow consent to and refusal of treatments to be based upon that information.. This conversation will also explore the patient's wishes so that they can be appropriately situated in the patient's views about life and death and honored in resuscitation decisions. This process will reinforce the dignity of the patient and meet the demands of respecting patient autonomy. 2. The law recognizes that there is an appropriate time and situation where some medical interventions are not to be employed because patients can no longer benefit from them. It allows patients to die a peaceful death as a matter of justice because certain invasive procedures are not warranted. 3. It can prompt patients and their families to consider comprehensive and specific advance directives that will place end-of-life decisions within the value context of the patient and promote care that is continuous with the values by which a patient has chosen to live and die.

 
 

3. DEFINITIONS.

1. CPR is defined as "cardiopulmonary resuscitation or a component of cardiopulmonary resuscitation." It does not include clearing a person's airway for purposes other than as a component of CPR. The components of CPR are: (a) Administration of chest compressions; (b) Insertion of an artificial airway; (c) Administration of resuscitative drugs; (d) Defibrillation or cardioversion; (e) Provision of respiratory assistance; (f) Initiation of a resuscitative intravenous line; (g) Initiation of cardiac monitoring. Individual interventions that may be part of the ongoing care of a patient independently of CPR are not considered components of CPR and may be continued even with a DNR order. 2. DNR COMFORT CARE indicates that there should be no CPR or component of CPR under any circumstances and that comfort measure only should be administered to the patient. 3. DNR COMFORT CARE-ARREST indicates that the DNR protocol should be initiated only after the patient has experienced cardiac arrest, i.e., the absence of palpable pulse, or respiratory arrest, i.e., the presence of agonal breathing. Prior to an arrest the patient should receive all appropriate care. Once the arrest occurs all treatment is withdrawn and the DNR COMFORT CARE protocol is instituted. 4. ATTENDING PHYSICIAN is the physician to whom a person, or the family of a person, has assigned primary responsibility for the treatment or care of the person or, if the person or the person's family has not assigned that responsibility, the physician who has accepted that responsibility.

 

4. DNR PROTOCOL.

1. Determine if the patient has a DNR COMFORT CARE identification. [EMS workers do not have to search a patient to make this determination; but they should be on the "look-out" for it.] 2. Make a reasonable effort to verify the identity of DNR COMFORT CARE patient (picture ID, identification by family, friend, or healthcare worker). [Verification is not necessary for patients or residents of healthcare facilities where the DNR COMFORT CARE order is on the chart.] 3. Verify the identity of a person (caregiver) issuing a verbal order.  4. When implementing a DNR COMFORT CARE order, caregivers WILL: (a) Suction the airway; (b) Administer oxygen; (c) Position for comfort; (d) Splint or immobilize; (e) Control bleeding; (f) Provide pain medication; (g) Provide emotional support; (h) Contact other appropriate healthcare providers. 5. When implementing a DNR COMFORT CARE order, caregivers WILL NOT: (a) Administer chest compressions; (b) Insert artificial airway; (c) Administer resuscitative drugs; (d) Defibrillate or cardiovert; (e) Provide respiratory assistance (other than that listed above). 6. If CPR has been initiated prior to the discovery of the DNR COMFORT CARE identification, CPR will cease immediately upon the discovery of the DNR COMFORT CARE identification. 7. Stipulations and immunities regarding DNR COMFORT CARE identification are specific for this protocol and do not extend to other forms of DNR orders.

 

5. FORMS OF DNR COMFORT CARE IDENTIFICATION.

1. There is a state mandated LOGO for DNR COMFORT CARE identification. CLICK HERE (then click on "forms" and then on "DNR Comfort Care") to view the LOGO. 2. The LOGO will be used on a bracelet, necklace, or wallet identification card. 3. DNR COMFORT CARE identification can be an addendum to the Living Will Declaration.

 

6. SECURING A DNR COMFORT CARE IDENTIFICATION.

1. Patient should discuss the mater with their physicians. 2. Physician (or certified nurse practitioner or clinical nurse specialist in collaboration with the physician) completes the DNR COMFORT CARE identification form. 3. Physician completes and issues to the patient the appropriate identification indication bearing the LOGO.

 

7. REVERSING THE DNR COMFORT CARE IDENTIFICATION.

1. The patient can reverse the DNR COMFORT CARE identification at any time orally, in written form, or by hand signal. 2. The patient can permanently remove or destroy the DNR COMFORT CARE identification. 3. The patient can revoke the living will declaration. 4. A patient's attending physician can revoke a DNR COMFORT CARE order. 5. The attorney-in-fact identified in a durable power of attorney for healthcare may reverse a DNR COMFORT CARE identification if it is determined to be inconsistent with the wishes of the patient expressed in a valid declaration.

 

8. IMMUNITIES FROM CRIMINAL AND CIVIL PROSECUTION OR PROFESSIONAL DISCIPLINARY ACTION.

Honoring the DNR COMFORT CARE identification is considered neither suicide nor homicide. Immunities are granted to: 1. Caregivers who honor the DNR COMFORT CARE identification. 2. Caregivers who make a reasonable effort to determine if a patient has a DNR COMFORT CARE identification. 3. Caregivers who end interventions after the DNR COMFORT CARE identification has been discovered. 4. Administrators of healthcare facilities. 5. Employees working under the direction of a physician. 6. Caregivers who perform CPR after the DNR COMFORT CARE identification has been revoked. There is no immunity if a DNR COMFORT CARE identification is issued contrary to a patient's or proxy's reasonable wishes or is contrary to reasonable medical standards..

 

9. CLINICAL JUDGMENTS OF PHYSICIANS.

1. Physicians may refuse to honor a DNR COMFORT CARE identification if it is deemed to be inappropriate. 2. Physicians who refuse to honor a DNR COMFORT CARE identification may not obstruct the patient or authorized proxy in the search for another physician or facility that will honor the DNR COMFORT CARE identification. 3. Physicians are not required to do CPR on a patient if they determine that the CPR will be futile.

 

10. CONTINUITY OF CARE

DNR COMFORT CARE identification will be portable from home to ambulance to healthcare facilities and from facilities to facilities. 1. The receiving facility will be notified of the DNR COMFORT CARE identification. 2. Orders will be written confirming the DNR COMFORT CARE identification and will accompany the patient.

 

11. PRESERVATION OF INDIVIDUAL RIGHTS.

1. DNR COMFORT CARE decisions will not affect either healthcare insurance or life insurance. 2. There is no presumption about the intent of an individual who does not have a DNR COMFORT CARE identification regarding the withholding or ending of CPR. 3. Rights to informed consent are preserved. 4. There are no limits or impairments to the right and responsibilities of authorized surrogates to make decisions about withholding or withdrawing life-sustaining treatments. 5. A living will declaration may include specific decisions about using, withholding, or ending CPR. Failure to include specific decisions does not preclude the withholding or ending of CPR.

 

12. SPECIAL PROHIBITIONS.

1. Physicians who think the DNR COMFORT CARE identification is inappropriate may not prevent, attempt to prevent, or delay the transfer of the patient to another physician or facility. 2. No one may purposely conceal, cancel, deface, or obliterate the DNR COMFORT CARE identification of another without that person's consent. 3. Falsification or forgery of a DNR COMFORT CARE identification is prohibited. 4. Personal knowledge that the decision to use, withhold, or end  CPR is contrary to a patient's wishes may not be withheld.

 

13. SPECIAL CAUTIONS.

1. If a DNR COMFORT CARE identification is made as an addendum to a Living Will Declaration, it may not go into effect unless the patient is terminally ill and has irreversibly lost decisional capacity since those two conditions are required to honor an advance directive in Ohio. 2. A DNR COMFORT CARE identification may be overturned by an attorney-in-fact designated by a Durable Power of Attorney for Healthcare unless the patient's wishes in this matter are explicitly stated. 3. Since a physicians may unilaterally revoke a DNR COMFORT CARE identification, patients and their proxies should be clear about their physicians' beliefs in this matter. 4. Physicians are not required to provide CPR for patients if the CPR is determined to be futile, even if the patients or their proxies demand CPR.