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Do Not Resuscitate Orders Policy

Policy Issue

A Do Not Resuscitate (DNR) order is "an order not to attempt Cardiopulmonary Resuscitation (CPR) in the event a patient suffers cardiac or respiratory arrest." CPR means measures to restore cardiac function or to support ventilation in the event of a cardiac or respiratory arrest. Examples include: mouth-to-mouth rescue breathing, direct cardiac injection, electrical defibrillation, and open chest cardiac massage.

Children and adults with developmental disabilities are more likely to have a "do not resuscitate order" placed on their medical chart than people without disabilities. Decisions on DNR orders are sometimes influenced by an assumption that the individual will have a shortened life-span.

Health care providers frequently underestimate the quality of life enjoyed by people with disabilities. Many people with developmental disabilities do not perceive the quality of their lives to be as negative as people without disabilities would imagine it to be.

The decision to place a DNR order on a person’s medical chart belongs to the physician. This decision may be made without anyone’s knowledge or consent. People with developmental disabilities are extremely vulnerable to DNR orders if they have no one in their lives to advocate for them. Consequently, people with developmental disabilities are sometimes not given life saving interventions when they might otherwise be given the intervention if the disability were not present.

At the end stages of life or an irreversible terminal illness, there comes a point where providing life-sustaining treatment (such as cardiopulmonary resuscitation) is futile and a DNR order is appropriate. In these cases, providing CPR either prolongs the dying process, or (and more likely) hastens it in a very unpleasant manner (e.g., punctured lungs, broken ribs from CPR on a frail or elderly person). People who are in the process of dying deserve care and comfort, not a prolonged dying process.

Consent to a DNR order lies at the heart of this issue. The people in our society who are the most vulnerable should not be at risk for DNR orders when they have a treatable health care condition nor should they be exposed to an unnecessarily prolonged dying process at the end stages of life.

Purpose

To ensure that people with developmental disabilities are not subjected to the inappropriate use of DNR orders.

Guiding Principles

  • A disability is not a terminal illness.
  • The decision of whether someone is at the end stages of life must be made independent of the person’s disability.
  • People at the end stages of life have the right to care and comfort measures, with an emphasis on alleviating pain.

Background

Historically, people with disabilities have been subjected to the inappropriate use of DNR orders, largely due to a lack of understanding on the part of medical personnel regarding the differences between an illness and a disability. Within the last ten years concern about this practice has escalated. BCACL, family members, health care providers, the Ministry of Health Services and the Ministry of Children and Family Development have all identified the need for medical advocacy in this area.

In 1999, Health Services for Community Living and the Ministry of Children and Family Development began tracking the number of DNR orders that had been placed on the medical files of adults with developmental disabilities. Although DNR orders are meant to be specific to a particular health situation and period of time, it was discovered that many DNR orders had been left standing on individuals’ files.

In recent years, heightened understanding about this issue has resulted in increased advocacy efforts by family members, care givers and health care providers to have physicians remove "standing" and other inappropriate DNR orders, especially when they have been linked to the presence of a disability rather than a specific illness.

Health Services for Community Living and the Ministry of Children and Family Development are presently looking at ways to refine and improve their tracking system. Orders that are known to be in place are now regularly reviewed to document when they are placed and when they will be reviewed. It appears that since the tracking began, the number of active DNR orders on the medical files of adults with developmental disabilities has decreased.

Policy Statements

  1. DNR orders should only be considered when someone is in the irreversible terminal stages of an illness or when the process of giving CPR could potentially cause significant trauma to the individual.
  2. Physicians should seek consent for a DNR order from the individual or a substitute decision maker before the order is placed on a person’s medical chart.
  3. People with developmental disabilities who are receiving treatment for a treatable health care condition should be given CPR, unless the process of giving CPR could potentially cause significant trauma to the individual.