Children with DNR orders and the liability risk for schools

by Crystal Phend

When children with complex chronic diseases have do-not-attempt-resuscitation orders in place, schools should honor them, the American Academy of Pediatrics urged.

More children with diseases that may involve sudden and potentially fatal attacks are attending school due to legal and societal trends over the past decade, according to a statement in the May issue of Pediatrics.

While these requests are honored in hospitals and nursing homes, schools may find it a more complex matter due to limited availability of school nurses and frequent lack of supporting state legislation and regulations.

Pediatricians thus have an important role in facilitating schools’ specific action plan for individual students and their families who don’t want CPR, the AAP said.

On the other hand, do-not-attempt-resuscitation requests for minors are not legally binding in many states, and schools may still face liability if personnel do not try to revive a stricken student even when such a request has been filed, the AAP warned.

The AAP first issued guidelines in 1994 supporting the ethical acceptability of forgoing CPR and other life-sustaining treatments for children and adolescents “when it is unlikely to be effective or when the risks outweigh the benefits, including the parents’ and child’s assessment of the child’s quality of life.”

This concern is justified, the AAP said, citing one recent review’s conclusion that only 10% of these children who are resuscitated survive to hospital discharge, and many suffer severe neurological sequelae.

While concerns have been raised about the effect of withholding CPR on staff and other students, the AAP explained that witnessing unsuccessful CPR can be traumatic too.

Do-not-resuscitate doesn’t mean “do nothing” or lower quality or less intensive care, the AAP noted.

Rather, these orders “should always include anticipatory and aggressive symptom control,” including pain managment, and address emotional and spiritual needs, according to the statement.

To ensure the effectiveness of the plan, the AAP suggested that pediatricians help school and local EMS staff to understand its implementation, calling the school nurse the best ally.

Specifics can be helpful.

For example, in the student’s individualized healthcare plan (or “504″ plan, referring to the section of federal law authorizing such advance planning), school staff should be directed “to provide specified comfort-care measures such as holding him or her, providing supplemental oxygen, or keeping the student warm,” the AAP said in the statement.

Other components that should be included in an individualized health plan are:

* Identification of staff members who should be informed of or educated about the do-not-attempt-resuscitation order
* Location to which the child will be moved in the case of serious distress or sudden death at school
* Protocols for notification of EMS, family, and primary care physician
* Protocols covering the child’s death in school, including who will pronounce the death
* A specific plan for removing the body from the school

The AAP cautioned that few states provide legal authority for advance healthcare directives for minors or explicit legal protection against liability for school personnel who honor do-not-attempt-resuscitation requests.

It recommended that pediatricians learn about their local state laws and regulations and respect school staff’s concerns in this regard.

Creating the legal framework for immunity from liability in these cases will be crucial for further acceptance of do-not-attempt-resuscitation requests in schools, the AAP noted.

A CDC survey indicated that only 46.2% of schools in 2006 had health services staff reported to follow do-not-attempt-to-resuscitate requests. Although the majority of schools still did not have a policy in place, this represented an improvement from the 29.7% of schools reporting such policies in 2000.

Crystal Phend is a MedPage Today Senior Staff Writer.

Originally published in MedPage Today. Visit MedPageToday.com for more pediatrics news.

email

Comments are moderated before they are published. Please read the comment policy.

Most Popular