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School Nurse told not to follow DNR order

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by Nurse Beth Nurse Beth, MSN (Columnist) Educator Writer Innovator Expert Nurse

Nurse Beth has 30 years experience as a MSN and specializes in Med Surg, Tele, ICU, Ortho.

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When DNR in the School Setting Conflicts with School Policy

What happens when you are a school nurse and your principal tells you to ignore a DNR on a severely disabled child?

School Nurse told not to follow DNR order
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Hello Nurse Beth,

I've asked this question in a forum, but I am interested in your opinion please? In our school division, if a student comes in with a chronic illness and has a DNR, and something happens to the student, per our policy we are obligated to initiate CPR and any other life saving measures that we are able to, such as calling 911, etc.

The rationale we are given, is that the other students might be upset if they saw us not doing anything to help the down student. A group of us are reviewing policies and are troubled by this policy. We are concerned that by not following the order we can possibly be charged with assault and battery, and or have disciplinary action taken against our licenses. We are also concerned that ethically we are not doing the right thing by our patient by not following the DNR order.

What are  your thoughts on this matter?

Dear Concerned,

First, a shout out to school nurses. You guys are amazing and I've always thought how challenging it must be to work as a nurse in a non-medical setting. I've wondered how much pressure there is to work outside of nursing practice standards.

Out of hospital (OOH) DNR orders have increased among children with terminal illnesses since children with disabilities are more mainstreamed in school following the Individuals with Disabilities Education Act (IDEA) of 1997. Laws and policies have not kept up with the resulting DNR in school setting issue.

Litigation

There has not been much litigation,  but here's one example.

A four year old (Minor M) with severe physical and mental disabilities was enrolled in a Massachusetts school (ABC school). Her parents provided a well written DNR that said she should receive:

  • rectal valium for a seizure
  • oxygen, suction and stimulation for a cardiopulmonary arrest
  • no CPR, no intubation, no defibrillation

ABC school had a conflicting “Preservation of Life” policy which required staff to “preserve and protect a child’s life by whatever means available to them” in the event of a crisis.

Ultimately the state court ruled against the school and in favor of the parent’s request. It went so far as to refuse to grant immunity to educators who said they would not go against their personal ethics and honor the DNR.

The decision to allow Minor M to die was rightfully the parent's, and not the educator's.

Pros and Cons

Proponents of honoring a DNR in the school setting cite a duty to protect the vulnerable child from unwarranted, painful medical interventions. Parents have a constitutional right to make this decision on behalf of their child.  To not honor the decision is to violate their constitutional rights. 

Once parents have made this extremely difficult, heart-wrenching decision, compliance should not be dependent upon setting.

In addition to citing Preservation of Life policies, opponents say a DNR should not be honored in the school setting in order to shield other children from the emotional trauma of witnessing an arrest seemingly without help being given. It could also be said that witnessing CPR being performed on a child or friend is traumatic.

Proponents say there should be a plan in place to manage the situation. Classmates should be quietly removed from the scene and given support. The dying child should be provided comfort and reassurance. 

The emotional trauma is mitigated by the responses of the adults present. Responses should be planned ahead of time.

Depending on the developmental stage of the students, it can be an opportunity to explore death and loss.  

In reality, most school districts do not have policies, neither pro nor con, in place.  Of those that do, the majority do not honor DNRs in the school setting.

However, school district policy should align with state law, and state law usually honors DNR orders.

State Law

Before you approach your principal or administrator, find out the law, if it exists, in your state.

It would be fortunate if you practice school nursing in Maryland. The Maryland Attorney General stated that “school officials may not perform emergency measures against the parents' decision” and school staff are to provide comfort and assurance.

Illinois courts follow public policy to preserve life, and do not allow “wrongful life” suits, which would protect you if you administered CPR and the child survived. But you could be liable for damages sustained from battery and any licensing sanctions.

Iowa's Attorney General holds the opinion that schools do not have to comply with DNR order because a school is not considered a health care provider.

Minnesota Board of Education requires an Individual Health Plan (IHP) to be developed as a response to a DNR order. The plan should be specific and include guidelines: 

  • to include EMS respondents in the plan
  • train and support school personnel
  • for annual review of the plan

Professional Organizations

In addition to your state BON,  look to your professional organizations for position statements and guidance.

As a school nurse, your professional organization is the National Association of School Nurses (NASN) and they have a position statement on DNR in the school setting.

It is the position of the National Association of School Nurses (NASN) that each student with a Do Not Attempt Resuscitation (DNAR) order benefits from having an Individualized Healthcare Plan (IHP) and an Emergency Care Plan (ECP) developed by the registered professional school nurse (hereinafter referred to as school nurse). While it is not a common occurrence for children with a Do Not Attempt Resuscitation (DNAR) order to die while at school, it is important to develop a plan in the event it does happen (DeMitchell & Thompson, 2017). Furthermore, a DNAR order for a student needs to be reviewed individually at the district level with input from the school district’s legal counsel for consideration of state and local laws and according to district DNAR policy.  As advocates for their students, school nurses work with the school team, the parents, and students’ healthcare provider to meet the students’ underlying healthcare needs as well as establish protocols and practices that enable students to receive best practice care throughout the entire course of their condition while they are in school.”

NASN is clear that each case must be examined on an individual basis in keeping with state law and local law. They focus on having an Individualized Healthcare Plan (IHP) created by a team that can include the parents, provider, school representatives.

Likewise, the National Education Association (NEA), the teacher’s union, says DNR orders should be honored and managed on a case-by-case basis.

The American Academy of Pediatrics (AAP)  supports “withholding of non-beneficial, life-sustaining medical treatment for children in accordance with medical, ethical and legal standards”.

Ethics

Thinking about administering CPR on a severely ill child with a DNR in order to keep your job has to cause moral distress for you and your colleagues.

You have accountability and responsibility to your nursing practice. What does that mean? Think the situation through and be very clear within yourself what you will do if a child with a DNR collapses with a cardiopulmonary arrest in your presence. Then be prepared to articulate your rationale for your actions and non-actions.

NASN's  Code of Ethics  states that school nursing "demands a vigilant focus on ethics".  When resolving a moral dilemma, apply the principles of beneficence (to do good), nonmaleficence (to not do harm), and autonomy (respect the right of others to govern their own lives).

Read Provision 6 of the ANA's Code of Ethics . Follow your moral compass.

Be an Agent for Change 

The problem is not going to disappear. Take a position. Be awesome.

If ever you had an opportunity to advocate for your students, this is it. It takes moral courage to have these conversations with your administrator. Be prepared and gather allies.

Once you learn the laws and regulation of your state, propose policy change and develop guidelines. Ethically, it could be argued the school has an obligation to accept a DNR order. There needs to be procedural guidelines around receiving and processing a DNR order. Consider steps such as:

  • school nurse to review order
  • co-ordinate meeting with nurse, administrator, parents, teacher 
  • development of a plan to be signed and dated by all
  • procedure for identifying child (bracelet)
  • process for revoking an order

School nurses are pivotal in creating  IHPs and ECPs for students, and in educating all stakeholders. With the school nurse's input, an IHP could include what to do if a child with a DNR is choking versus arresting. Staff need to be educated that a DNR does not mean they do nothing. Depending on the plan, suctioning, positioning for comfort, giving oxygen are all helpful.

If there is an incident, have a debriefing and allow everyone to share their concerns.

Finally, consider writing an article for the Journal for School Nursing or NASN School Nurse about changing practice in your district. You can influence others and be an agent for good.

Best wishes,

Nurse Beth


REFERENCES
Jessica Adelman, The School-Based Do-Not-Resuscitate-Order, 13 DePaul J. Health Care L. 197 (2010) Available at: https://via.library.depaul.edu/jhcl/vol13/iss2/3

DeMitchell, T. A., & Thompson, W. C. (2016). Do Not Attempt Resuscitation Orders in Our Schools: The Unthinkable Ethical Dilemma for Educators. Rutgers JL & Pub. Pol'y, 14, 287.

Mawdsley, R. D. (2010). The Use of Do Not Resuscitate Orders (DNR) in School Settings. Education Law Reporter, 257, 536.

Hi! Nice to meet you! I love helping new nurses in all my various roles. I work in a hospital in Staff Development, and am a blogger and author.

19 Followers; 115 Articles; 238,212 Profile Views; 2,169 Posts

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TriciaJ has 39 years experience as a RN and specializes in Psych, Corrections, Med-Surg, Ambulatory.

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Thanks for the very eye-opening article.  I lurk on the school nursing site and know that their jobs aren't easy.  As a former corrections nurse I understand the pressure of practicing nursing in a non-medical setting.

I had no idea there were children with DNR orders and school bureaucrats who take it upon themselves to supercede them.

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FacultyRN has 13 years experience as a MSN, RN.

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This really irks me.

Parents have the right to make medical decisions for their children. School principals can't override parental rights, protected by law, to make their own medical decisions for children... in this case, not even considering the best interest of the child with the DNR, but feelings of others. Children belong to their families, not to a school.

Additionally, school policies can't override that a nurse's primary duty is to her patient. A school administrator does not have the authority to override that duty, nor guide nursing practice. I'd be making it very clear that my nursing duty, as a requirement of my license, was to serve this child according to his/her needs and parents' legally presented wishes.  My duty is also to practice according to my license's scope and standards, as well as according to the best practice education I've received in nursing.  Someone with a degree in education doesn't get to make my nursing decisions. Even nurse co-workers don't get to make my nursing decisions, although their feedback and ideas are well-received.

A duty to protect the general student body's feelings doesn't exist.  And this principal has clearly never observed a resuscitation scene, which can be much more traumatic to witnesses than a peaceful passing.

Thankful for school nurses and what they do!

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Hoosier_RN has 27 years experience as a MSN and specializes in dialysis.

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WOW!  If I were in the situation of worrying about other kiddos thinking I'm not doing anything, I would get assist, pronto, to get the sick kiddo out of the room/view. That's basic dignity. A family has every right to designate DNR for a sick child and expect it to be carried out

Edited by Hoosier_RN

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TriciaJ has 39 years experience as a RN and specializes in Psych, Corrections, Med-Surg, Ambulatory.

16 Followers; 3,903 Posts; 42,660 Profile Views

3 hours ago, FacultyRN said:

This really irks me.

Parents have the right to make medical decisions for their children. School principals can't override parental rights, protected by law, to make their own medical decisions for children... in this case, not even considering the best interest of the child with the DNR, but feelings of others. Children belong to their families, not to a school.

Additionally, school policies can't override that a nurse's primary duty is to her patient. A school administrator does not have the authority to override that duty, nor guide nursing practice. I'd be making it very clear that my nursing duty, as a requirement of my license, was to serve this child according to his/her needs and parents' legally presented wishes.  My duty is also to practice according to my license's scope and standards, as well as according to the best practice education I've received in nursing.  Someone with a degree in education doesn't get to make my nursing decisions. Even nurse co-workers don't get to make my nursing decisions, although their feedback and ideas are well-received.

A duty to protect the general student body's feelings doesn't exist.  And this principal has clearly never observed a resuscitation scene, which can be much more traumatic to witnesses than a peaceful passing.

Thankful for school nurses and what they do!

I can't "like" this post enough.  It hit all the nails squarely on the head.

 I try to imagine what all transpires before a child has a DNR placed.  The parents would likely have witnessed incredible suffering,  had at least one lengthy conversation with at least one doctor, maybe their pastor.  Maybe they fought with each other about the best course of action.  They likely got pushback from family.  This had to be one of the hardest and most emotionally-wrenching decisions they ever made. 

For some behind-the-desk administrator to puff up about "school policy" and what the optics might be - the sheer arrogance of it makes me seethe.

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Nurse Beth has 30 years experience as a MSN and specializes in Med Surg, Tele, ICU, Ortho.

19 Followers; 115 Articles; 2,169 Posts; 238,212 Profile Views

18 hours ago, TriciaJ said:

Thanks for the very eye-opening article.  I lurk on the school nursing site and know that their jobs aren't easy.  As a former corrections nurse I understand the pressure of practicing nursing in a non-medical setting.

I had no idea there were children with DNR orders and school bureaucrats who take it upon themselves to supercede them.

I didn't either, until I researched it! But it's a really good opportunity for advocacy, and school nurses are positioned to move this forward 

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14 Followers; 4,219 Posts; 32,810 Profile Views

Excellent article/response to the inquiry. This was very interesting to read.

Agree with all those above. An additional thing that stuck out to me is--does anyone else find their rationale slightly appalling?

 

On 6/3/2020 at 3:04 PM, Nurse Beth said:

The rationale we are given, is that the other students might be upset if they saw us not doing anything to help the down student.

This is terrible! First of all, no one is going to be doing nothing or "not doing anything." There is plenty of care to be rendered that is within the family's wishes (comfort measures, etc). Secondly a school of all places should understand the importance of (and be able to figure out how to handle) age-appropriate education to the extent that this is able to be done while respecting the patient's privacy. If nothing else, other children should be immediately moved away and reassured that the nurse/team is taking care of/helping their classmate.

In any case the rationale for the policy sends a horrible message that we do things for appearances even if they violate someone else's clearly communicated wishes about their own person/body/life [or that of their beloved child in this case].

I think it is extremely difficult for anyone to think of a child dying. This is probably even further compounded in a non-family, non-medical setting where none of the others present are medical or nursing professionals. It's a very common/normal emotion to want to be able to say that everyone tried everything possible. This soothes people's grief because that's the way we are conditioned.

In addition to the excellent advice in the response, I think ^ this is important because school personnel may likely need to be convinced to (emotionally) see (feel) things a totally different way in this scenario. They need to understand that honoring one's wishes is to care for them; it is the loving, accepting, ethical thing to do. It does not involve doing "nothing" or causing anyone's death or even personally "letting" them die really.

 

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TriciaJ has 39 years experience as a RN and specializes in Psych, Corrections, Med-Surg, Ambulatory.

16 Followers; 3,903 Posts; 42,660 Profile Views

On 6/4/2020 at 6:23 AM, FacultyRN said:

 

A duty to protect the general student body's feelings doesn't exist.  And this principal has clearly never observed a resuscitation scene, which can be much more traumatic to witnesses than a peaceful passing.

 

Yes.  The principal's decision involves an appalling level of ignorance and arrogance.

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