The following is excerpted, with minor adaptations, from Hoffmann, Levin & Boyle’s Nursing Home Ethics Committee Handbook.
Statement of need for the policy or protocol
The policy should explain why it was developed, i.e., in response to what need.
Statement of purpose
The purpose of the policy is its underlying reason and what it purports to accomplish.
Statement of the principles underlying the policy
This provides staff with some sense of the basis for the policy so that they understand its rationale.
Definitions of the terms used
It is important that a policy be clear and not use vague or undefined terms that could be interpreted in different ways. For this reason a policy should have a definition section where such terms are clearly defined.
Substantive rules or guidelines
This is the meat of the policy. It should set out the decisional criteria the institution wants caregivers to use and under what circumstances. For surrogate decision making, for example, it might state when surrogates may make medical decisions for incapacitated patients and who qualifies as a surrogate.
For decisions to withhold artificial nutrition and hydration for incapacitated patients, it should state when such decisions can be made (e.g., when the patient is terminally ill or in a persistent vegetative state) and who can make them.
Process for implementation
The policy and procedures should spell out who does what, and when. Specifically, Choice in Dying recommends that the following issues be addressed:
- who initiates the use of the protocol, and when;
- what needs to be included in the patient's records;
- what consultations may be required;
- what notification may be required and to whom;
- how to resolve disagreements among those involved in using the protocol;
- what sanctions can be imposed for violation of the protocol. (p. 3)
Once the policy or protocol has been developed, it must be approved by the appropriate authorities within the facility. This may include the medical staff, the director of nursing, the administrator, and the board of directors or trustees. In some cases, provisional approval may be appropriate so that the policy can be evaluated after a set period of time and revised to correct any problems or deficiencies.
Sample Do-Not-Attempt-Resuscitation (DNAR) Policy
Need for Policy—Between 1 January and 30 June 2012, sixteen cases involving a conflict between a physician and a patient's family over the writing of a do not attempt resuscitation (DNAR) order came to the ethics committee. In 4 of the 6 cases, the physician wrote the order without obtaining the consent of the family members. In 2 of the 6 cases, the family members wanted the physician to write a DNAR order but the physician felt that such an order would not be appropriate. This policy has been developed to provide guidance to physicians and other health care providers in drafting DNAR orders.
Purpose—The primary purpose of this policy on DNAR orders "is to ensure that decisions regarding cardiopulmonary resuscitation (CPR) for particular patients are made through a medically responsible, ethical, and sensitive process that protects the rights of the patient. The secondary purpose is to ensure that there is adequate communication between the patient and those involved in the patient's care."
A. A DNAR order may be appropriate in a variety of clinical situations and may be compatible with aggressive and intensive medical care or participation in research. A DNAR order has no implication for any other treatment decision. For example, it does not imply that any other forms of medical care or research be withheld. Decisions about other medical interventions should be made independently.
B. All treatments that impose undue burdens on the patient without overriding benefits, or that simply provide no benefits may justifiably be withheld or withdrawn. There is no ethical distinction between failing to initiate and stopping therapy. A justification that is adequate for not commencing treatment is also sufficient for ceasing it.
Cardiopulmonary arrest. The cessation of cardiac or respiratory function.
Cardiopulmonary resuscitation. Immediate, aggressive treatment of cardiopulmonary arrest.
DNAR order. A specific order from a physician not to attempt cardiopulmonary resuscitation if a patient suffers cardiac or respiratory arrest.
Terminal illness. An incurable or irreversible condition caused by injury, disease or illness which to a reasonable degree of medical certainty makes death imminent and from which there can be no recovery despite the application of life-sustaining procedures.
Decision-making capacity. The ability to comprehend information relevant to a decision, deliberate about choices in accordance with personal values and goals and communicate such choices to caregivers.
No medical benefit. CPR is defined as having no medical benefit when, in the considered medical judgment of the responsible senior physician, the patient would not survive CPR.
In the absence of a DNAR order, cardiopulmonary resuscitation must be attempted. However, there are circumstances under which it is medically, legally, and ethically appropriate to consider not providing CPR attempts. This section sets forth criteria for determining when such circumstances are present.
A. CPR should not be initiated when:
- A patient with decision-making capacity or his/her legal guardian has requested that CPR be withheld.
- A patient who lacks decision-making capacity has previously executed a valid living will or durable power of attorney that expresses a wish not to be resuscitated or names a surrogate who makes the decision to withhold CPR, and that advance directive is still in effect (e.g., has not been rescinded by the patient, has not expired, etc.)
- In the considered medical judgment of the responsible senior physician, the patient would not survive CPR.
B. A decision not to initiate CPR should be considered and discussed with the patient or the patient's surrogate under any of the following circumstances:
- The patient is terminally ill.
- The patient has a severe and irreversible illness or disabling condition.
- The patient has suffered an irreversible loss of consciousness.
- The patient is likely to lose decision-making capacity.
- There is likely to be no medical benefit from CPR.
A. Patients with decision-making capacity:
- Thorough knowledge of the patient's medical condition is necessary before consideration of a DNAR order. The responsible senior physician should communicate all pertinent facts regarding the patient's medical condition to the patient. The physician must provide the patient with adequate information regarding potential resuscitative measures to enable the patient to make an informed decision. The information provided should include that CPR may involve such procedures as chest compression, administration of various medications, electrical shocks to restart the heart, intubation, and placement on a ventilator.
- Discussions about resuscitation should occur as early as possible in the patient's course, when the patient can participate and make an informed decision. Discussions about resuscitation may also include primary care physicians, primary care nurses, and any other staff members who may have pertinent input about the patient. Discussions may include family members if the patient consents.
- The responsible senior physician should obtain clear oral or written consent from the patient not to initiate CPR.
- If CPR is judged to be of no medical benefit, the responsible senior physician must inform the patient and discuss it with him/her. If the patient disagrees with the physician's recommendation not to initiate CPR, the disagreement should be resolved as described in paragraph C.
- The DNAR order should be reevaluated and renewed anytime there are significant changes in the patient's condition or treatment circumstances, at the patient's or surrogate's request, or periodically as required by procedures of the patient care unit.
- When the patient is discharged from the institution, the DNAR order must be noted in the final written progress note and discharge summary. Patients previously discharged from the institution with a DNAR order should have their clinical status reassessed upon subsequent admissions, and, if indicated, have a DNAR order rewritten.
B. Patients without decision-making capacity:
- The above procedures (1-5) all apply but the decision is made by surrogates.
- A surrogate is an individual who can make health care decisions for another whose decision-making capacity is compromised. Unless another legally valid surrogate has been previously designated by durable power of attorney, guardianship, or similar proceedings, the surrogate should be determined in the following priority: (1) spouse or domestic partner, (2) adult child, (3) parent, (4) adult sibling, (5) other person who signs an affidavit attesting to knowing the person well enough to inform decision-making. (If an individual with a higher priority is not reasonably available, the individual next in the order may act as surrogate.)
- A surrogate's decision about CPR should be based on the patient's previously expressed preferences, or if those are unknown, in accordance with the patient's best interests. The surrogate should not make a decision contrary to the known preferences of the patient.
- In the case of a cognitively incapacitated patient without an appropriate surrogate or evidence of advance directives, the responsible senior physician is required to obtain a consultation from the institution's ethics committee.
C. When there is disagreement about providing CPR:
When there is a disagreement about providing CPR either between the patient or surrogate and the physician, the family and the physician, or members of the health care team and the physician, further discussion and consultation with the institution's ethics committee is warranted. In general, the decision of a patient with decision-making capacity or of a designated surrogate should be honored, unless the responsible senior physician finds the request to be medically ineffective. A physician who finds the decision medically or morally unacceptable, but not medically ineffective, and is unwilling to carry it out should transfer responsibility for that patient to an equally qualified physician.
- The responsible senior physician must write a note in the patient's medical record indicating that resuscitation has been discussed with the patient/surrogate. The indication and rationale for the DNAR decision must be noted in the patient's progress notes, including documentation of the oral or written consent of the patient/surrogate to not initiate CPR, if applicable.
- A DNAR order must be entered into the MIS (Medical Information System).
- The decision not to attempt resuscitation must be communicated to all appropriate medical and nursing staff. This includes application of the designated DNAR sticker to the front cover of the patient's chart.
- If the patient is discharged, a Maryland MOLST form should be completed reflecting the resuscitation status.
Adapted from the policy developed by The Clinical Center at the National Institutes of Health. Policy and Communications Bulletin, Medical Administrative Series, nos. 91-97 (1 Nov. 1991).