Advanced Directives Regarding CPR - Cardiopulmonary Resuscitation and DNR - Do Not Resuscitate

Effective Date: [Original NPP Date]
Revised Date: [Current Date]

Goal

To honor residents' advanced directives regarding end-of-life care. The rights of the resident supersede the rights of the Power of Attorney.

Policy

It is the policy of this facility to honor residents' advanced directives regarding end-of-life care. Employees should not witness any legal documents. The resident and/or responsible party should be directed to the Administrator for such matters.

Procedure

1. Initial Review and Consent:

   • Prior to or at the time of admission, the facility will review and hand out the Cardiac/Respiratory Arrest Explanation sheet to the competent resident or responsible party/conservator of the incompetent resident.
   • After review, the appropriate party will check the appropriate box on the CPR/DNR Consent Form and sign the form.
   • If the incompetent resident has no family, it will be specified that there is no family on the CPR/DNR Consent Form, and "undecided" will be checked.

2. Executing Orders:

   • CPR will be performed at all times unless a DNR order has been completed by the physician and entered on the resident’s medical record.
   • Based on the CPR/DNR Consent Form, the nurse is responsible for obtaining an order from the physician for the resident’s code status.
   • If the decision is “DNR” at any point, the physician must write a “DNR” order. The physician will determine if the resident is capable of making their own decision and document whether or not the resident is competent, including discussion with the competent resident or responsible party/conservator.

3. Telephone Orders:

   • If the attending physician is unable to come to the facility to enter a DNR order, a telephone order for “DNR” may be taken by two (2) licensed nurses (one of whom must be an RN) simultaneously. Both nurses will sign the order.
   • The physician must cosign the telephone order at his/her next visit.
   • A fax order for CPR/DNR is also permitted.

4. Changing Code Status:

   • The resident or responsible party/conservator has the right to change the code status at any time. The physician is notified, and a new Code Status order is obtained.
   • The old form is removed from the chart.

5. Review and Communication:

   • The “DNR” order will be reviewed periodically by the physician and during the Resident Care Plan Meeting with the resident or responsible party/conservator.
   • In cases where the surrogate decision maker wishes to change a previous CPR determination, the surrogate should call Social Services to arrange a meeting to complete the necessary paperwork. If unable to come to the facility, they will be requested to call the attending physician.

6. Transfer of Residents:

   • When a resident is discharged/transferred to a hospital or other facility, the “DNR” order will be communicated via the DNR Order Transfer Policy.

Department of Mental Retardation Client (DMR)

1. Identification:

   • For residents who are also DMR clients, the face sheet of the medical record shall identify the resident as a DMR client and will include the name of the case manager, the case manager’s supervisor, and the DMR regional health care coordinator with their contact information.

2. Documentation and Communication:

   • A copy of the Department of Health memorandum regarding DNR orders for clients of the Department of Mental Retardation will be included in the medical record of all residents who are clients of DMR.
   • All contemplated DNR orders will be communicated to the case manager and regional health coordinator by Social Services.
   • Documentation by the attending physician that the resident is in a terminal condition or permanently unconscious is required, along with a second physician’s opinion.

3. Disputes:

   • In the case of disputes regarding DNR orders, the Administrator will consult with the facility’s Medical Director and Legal Counsel to resolve the issue.

Documentation

1. Cardiac/Respiratory Explanation Sheet:

   • Every cell in the body needs oxygen to live. The respiratory and circulatory systems provide oxygen to all parts of the body.
   • Clinical death occurs when both heartbeat and breathing stop. Biological death occurs when body cells are deprived of oxygen for four (4) minutes or more, causing irreversible damage.
   • Cardiopulmonary resuscitation (CPR) combines artificial ventilation and circulation to provide oxygen and circulating blood to a resident in cardiac arrest.
   • In elderly residents, CPR has minimal efficacy, with a survival rate of only 0 to 1.7%. Most residents who receive CPR do not survive beyond three months and often experience prolonged suffering in the hospital.

2. DNR Order Transfer Policy:

   • The facility recognizes and honors existing DNR orders when admitting residents if communicated via an approved DNR Transfer Form, DNR bracelet, or W10 form.
   • During discharge/transfer, the Charge Nurse confirms the existence of a valid DNR order and completes a DNR Transfer form or provides an orange DNR bracelet.

Pronouncement of Death by a Registered Nurse

1. Goal:

   • To ensure adherence to all applicable state laws regarding R.N. pronouncement of death.

2. Definitions:

   • Determination of Death: Observation and assessment that a person has ceased vital bodily functions irreversibly.
   • Pronouncement of Death: The declaration by the Registered Nurse who has made the determination of death.
   • Anticipated Death: Death expected due to illness, infirmity, or disease, as determined by the attending physician.

3. Procedure:

   • An attending physician who determines that the prognosis for a resident is an anticipated death will document this in the resident’s medical record and write an order authorizing a Registered Nurse to determine and pronounce death.
   • The determination and documentation by an attending physician are valid for a period not exceeding 120 days.
   • A Registered Nurse who determines that vital bodily functions have ceased will document the clinical criteria for such determination and pronouncement in the resident’s medical record, notify the physician, and complete the death certificate.

References

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]