DNR in public school

KelRN215, BSN, RN · Mar 27, 2015

I am interested in the question but I'm having trouble imagining under what circumstances someone with a DNR would be attending school.

I can think of many examples. I had a patient with multiply relapsed AML earlier this year. With her final relapse, there was nothing to be done except for a phase I trial. When that didn't work, the focus shifted to comfort care and she was made a DNR. She desperately wanted to go back to school and did after being released from the hospital.

I've known many kids with cancer over the year who have their DNRs signed before they stop attending school. Sometimes you know there is really nothing more to be done and that CPR would be futile given the underlying disease but the child still feels well enough to go to school.

Then there are the chronic kids. I've known several kids in those types of situations- the genetic diseases, the metabolic diseases, the neurodegenerative diseases, who have active DNR orders long before they're actively dying.

NutmeggeRN, BSN · Mar 27, 2015

I'm not a school nurse, but from an EMS perspective I was called out a few years ago to a middle school for a teacher that suffered a cardiac event. When we arrived he had a DNR wristband on and it was valid. The administration demanded that we not honor the DNR because they expect any emergency to be transported out. No school nurse was there to give any info, and we wound up leaving him in care of PD until the funeral home arrived. After that, the school put a policy in place for persons w/ DNRs, but that first time was a mess.

ugh.....

Flare, ASN, BSN · Mar 27, 2015

I had a student a number of years ago with terminal cancer- I was aware that there was going to be a DNR signed and had the discussion with the parents that they would need to get me a copy to have on file in school in order for it to be honoured should something happen during school hours, but sadly he got too weak to continue school before the order could be shared with me and before long it wasn't necessary.

OldDude · Mar 27, 2015

I can think of many examples. I had a patient with multiply relapsed AML earlier this year. With her final relapse, there was nothing to be done except for a phase I trial. When that didn't work, the focus shifted to comfort care and she was made a DNR. She desperately wanted to go back to school and did after being released from the hospital.
I've known many kids with cancer over the year who have their DNRs signed before they stop attending school. Sometimes you know there is really nothing more to be done and that CPR would be futile given the underlying disease but the child still feels well enough to go to school.
Then there are the chronic kids. I've known several kids in those types of situations- the genetic diseases, the metabolic diseases, the neurodegenerative diseases, who have active DNR orders long before they're actively dying.

I guess I had a different definition of "attending school" in my mind but I can see how those examples would apply. Thank you.

bell1962 · Mar 27, 2015

We had a sudent many years ago with an DNR. He had multiple disabilities, didn't communicate,couldn't really move on his own, was blind, and basically just at in his wheelchair or laid on a mat all day. He lived in a nursing home and had the DNR order. The school developed a strict policy on how to impliment the order in school: who to contact, what to do with the other students in the classroom, etc. Luckily we never had to face the situation but I think we were as prepared as we could have been.

CAdreamerRN · Apr 8, 2015

We have a kid with a DNR in the district - medically fragile and severely disabled - we do not honor DNRs in school and have to make parents aware.

ixchel · Apr 8, 2015

How does this work, though? A DNR indicates that a person or person's guardian does not consent to resuscitation. Isn't it assault to not respect that?

OldDude · Apr 8, 2015

How does this work, though? A DNR indicates that a person or person's guardian does not consent to resuscitation. Isn't it assault to not respect that?

I guess if the parents were informed of the district policy and enrolled the child, knowing that to be the policy, they would be implying consent for the district to perform resuscitation efforts.

How's that for amateur nurse lawyering :)?

Red Kryptonite · Apr 8, 2015

We have a kid with a DNR in the district - medically fragile and severely disabled - we do not honor DNRs in school and have to make parents aware.

What an awful policy. Why would anyone force parents, who've already had to make the horrible decision to make their kid a DNR, to choose either to deny their kid the chance to go to school, or consent to futile battery upon that child's diseased body that will not save life or preserve health but only cause further pain and suffering?

Farawyn · Apr 8, 2015

Wait, if there is a legal DNR how can it not be honored? Does school policy trump that?

KelRN215, BSN, RN · Apr 8, 2015

We have a kid with a DNR in the district - medically fragile and severely disabled - we do not honor DNRs in school and have to make parents aware.

A DNR is a legal document, I don't see how it's up to a school to tell parents that the heart wrenching decision they made about their child's resuscitation status is irrelevant during school hours. You wouldn't have moral or ethical issues about performing CPR on an end-of-life child who had a valid DNR order because of "district policy"?

CAdreamerRN · Apr 9, 2015

It's not the school or the district alone, it's in the state ed code. It's for school-based settings, there are other options for parents to choose for their kid. It's probably to cover for some employee that doesn't understand what DNR is and would think they were helping. Our policy is to perform CPR until EMS gets there and send a copy of the DNR with the kid to the hospital. Court-ordered DNRs are taken into account on a case by case basis, so if parents are really pushing for no assistance while their child is at school, then I suppose there is a way around it. I'm not advocating either way, just answering the original question.