/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/administrative/,/policies/clinical/uw-health-clinical/administrative/legally-driven-care/,

/policies/clinical/uw-health-clinical/administrative/legally-driven-care/1213.policy

201711317

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,Administrative,Legally Driven Care

Do Not Resuscitate (DNR)/No CPR Order (1.2.13)

Do Not Resuscitate (DNR)/No CPR Order (1.2.13) - Policies, Clinical, UW Health Clinical, Administrative, Legally Driven Care

1.2.13


UW HEALTH CLINICAL POLICY 1
Policy Title: Do Not Resuscitate (DNR)/No CPR Order
Policy Number: 1.2.13
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: August 28, 2017


I. PURPOSE

To establish a mechanism to implement Inpatient and Out of Hospital Do Not Resuscitate/No CPR Orders in
the appropriate settings across UW Health after the decision to withhold resuscitation has been made.

To ensure that the decision to withhold cardiopulmonary resuscitation is made in the framework of a
medically responsible, ethical, and sensitive process that protects the rights of patients and adheres to
applicable law.

II. DEFINITIONS

A. No CPR/Do Not Resuscitate (DNR) Order: a decision to forego the otherwise automatic initiation of
cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. There are numerous synonyms for a
DNR order, including "No CPR", "Do Not Attempt Resuscitation (DNAR"). This document will use “No CPR”
to refer to this order except for out of hospital orders, where the term “DNR” is used in state law.
B. Cardiac arrest – cessation of cardiac output (no pulse) this event is distinct from heart failure, shock or
respiratory failure. Limitations of treatment for heart failure (for example vasopressors, cardioversion) or
respiratory failure (for example intubation) are not covered under No CPR/DNR. Such limitations require a
goals of care conversation and should reflect the patient’s values and goals with respect to the outcomes
possible for that patient with those treatments. Limitations of treatment are covered under policy 8.25.
C. Decision-making capacity: means the ability to receive information and understand the consequences of
one’s decision, and to communicate decisions to such an extent that the individual patient can manage his
or her own health care decisions. Mere old age, eccentricity or physical disabilities, singly or together, are
insufficient to make a finding of incapacity. Mere disagreement by the patient with the health care providers
is insufficient for a finding of incapacity.
Individuals with court-appointed guardians may still have some capacity to participate. Minors (children
under age 18), as a general rule, and by law are not capable of making their own health care decisions
without parental consent, except for emancipated minors or mature minors (See UWHC policy #4.17,
Informed Consent). However, their views should be solicited and should play a role in health care decisions.
D. Authorized Representative: adult who is authorized to make decisions on behalf of a patient (when the
patient is without decision-making capacity) as described in UWHC policy #4.17, Informed Consent.

III. POLICY ELEMENTS

A. It is the policy of UW Health to provide quality medical care to its patients, including resuscitation of patients
in the event of sudden cardiac arrest, whenever such efforts have a reasonable chance of prolonging life
and are consistent with the patient’s wishes. When the patient cannot decide for him/herself, the patient’s
Authorized Representative should make the decision based upon his/her best assessment of what the
patient would choose for him/herself. However a physician’s order not to provide CPR is medically, ethically,
and legally appropriate in circumstances where CPR would be medically ineffective or the attending
physician and the patient agree, after discussion, that the order is in the patient’s best interest. Even when
resuscitation is judged to be medically ineffective, the attending physician should discuss the order with the
patient or the patient’s Authorized Representative.
B. UW Health strongly encourages a conversation between the health care team and the patient or the
patient’s Authorized Representative to discuss the patient’s larger goals of care. This is especially important
for seriously ill patients and patients with chronic illness. Efforts should be made to ensure that patients and
providers understand the range of possible outcomes and whether the patient’s goals are achievable within
these constraints.
C. Adult patients have the right to refuse any medical intervention, including CPR and other lifesaving
procedures. Patient refusal of lifesaving procedures should be respected when the patient possesses
decision-making capacity with regard to refusal. If a patient who lacks decision-making capacity refuses
lifesaving procedures, the patient’s expression of refusal by itself is not an adequate basis upon which to
issue a No CPR Order. Confirmation by the patient’s Authorized Representative is required.
D. The existence of a No CPR Order for a patient should not influence any decision to provide any other type of
life sustaining treatment including intubation for respiratory failure or cardioversion for a perfusing


UW HEALTH CLINICAL POLICY 2
Policy Title: Do Not Resuscitate
Policy Number: 1.2.13


dysrhythmia (e.g. atrial fibrillation with RVR). The use of life sustaining treatments should be discussed
separately and should be considered only in relation to how these treatments might achieve the patient’s
goals.

IV. ESTABLISHING AN INPATIENT NO CPR ORDER

A. When a patient with decision-making capacity expresses a desire to forgo CPR in the event of cardiac
arrest:
i. The patient should be asked whether he/she has an advanced directive so the physician and
nursing staff can be informed about the patient’s wishes.
ii. The attending physician or another appropriate member of the care team should discuss with the
patient – at or before the time the physician judges a No CPR Order to be appropriate – the
burdens and possible benefits of CPR to determine if the potential outcomes align with the patient’s
goals. Decisions to pursue a No CPR Order should be reached consensually by the patient and
physician.
iii. The patient’s family should be informed of these discussions unless the patient objects.
B. If a patient lacks decision-making capacity and has a written advance directive, the attending physician or
another appropriate member of the care team should discuss the burdens and benefits of CPR in the event
of cardiac arrest with the patient’s Authorized Representative and the patient’s family in relation to the
patient’s goals or preferences which may or may not be outlined in the advance directive.
C. If CPR is likely to be ineffective or harmful to a patient based on clinical judgment (i.e. unlikely to be
beneficial, is highly burdensome, or highly unlikely to result in meaningful survival) the attending physician or
another appropriate member of the care team should engage in an active dialogue with the patient or their
Authorized Representative regarding the plan of treatment and expected outcomes. The physician should
inform the patient (or the patient’s Authorized Representative) of the ineffectiveness of CPR and may
recommend a No CPR Order.
D. If an attending physician determines that CPR will be physiologically futile (for the purpose of this policy,
physiologically futile meaning no chance of restoring sustained spontaneous circulation e.g. decapitation,
uncontrolled exsanguination) he/she will inform the patient or patient’s Authorized Representative of the
issuance of a No CPR Order. If the patient’s clinical situation changes and CPR is no longer physiologically
futile the No CPR Order should be reconsidered.
E. If a patient lacks both decision-making capacity and an identifiable Authorized Representative, and in the
attending physician’s judgment CPR would not have a reasonable chance of prolonging life or would not be
in the best interests of the patient, ethics consultation is recommended. The UW Health Attorney-On-Call
can be contacted to determine whether appointment of a guardian should be sought (Refer to UWHC policy
#8.25, Guidelines for Decisions to Limit Life-Sustaining Medical Treatment for more information).
F. If circumstances arise in which there is disagreement between the attending physician and the patient, the
patient’s family, and/or the patient’s Authorized Representative concerning the issuance of a No CPR Order
following a discussion of benefits and harms in relation to the goals of the patient, ethics consultation is
recommended.
G. Procedure for Implementing a No CPR Order.
i. The order must be recorded in the medical record and signed by the attending physician within 24
hours.
ii. The reasons for the order, as well as the circumstances regarding the patient’s consent to it (or
consent by the patient’s guardian or health care agent, if appropriate), should be recorded in the
medical record, such as in a Progress Note or Conference Note.
iii. At the time the order is written, the patient should be given a purple No CPR wristband, which
signifies the patient’s status while hospitalized. Wristband use by patients allows effective
communication of their wishes and the existence of the order (Note: The color-coded wristbands do
not constitute a valid DNR Order for discharged patients).
a. Patients may decline to wear a wristband, but should be advised that in the event they
have a cardiopulmonary arrest, staff may begin CPR until such time as the patient’s
wishes are known.
iv. Prior to discharge, providers may consider Out of Hospital DNR Orders for patients (refer to V.
Procedures for Out of Hospital DNR Orders).


UW HEALTH CLINICAL POLICY 3
Policy Title: Do Not Resuscitate
Policy Number: 1.2.13


v. When a No CPR Order is entered into the medical record, it must be communicated to the relevant
providers who care for the patient. The patient header in the medical record indicates current code
status. The members of the patient’s health care team have the responsibility to know when an
order has been issued and to inform other care providers of the patient about the order and about
any rescission of the order, if it occurs.
vi. If a member of the patient’s health care team objects to participation in implementation of a No
CPR Order, arrangements should be made so that implementation of the order is not
compromised.
vii. The No CPR Order should be reassessed as part of the ongoing evaluation of a patient. The No
CPR Order may only be revoked after a discussion between the attending physician or another
appropriate member of the provider team and the patient (or patient’s Authorized Representative).
Reassessments of the No CPR Orders should be documented in the medical record. If the No CPR
Order is revoked it should be communicated to all relevant members of the health care team.
viii. When the patient is transferred to another service, a No CPR Order should be reviewed by the
attending physician or another appropriate member of the care team and reconciled.
ix. When a patient has been transferred to UW Hospitals with an active DNR/No CPR Order, the
Order will be honored, but needs to be readdressed within 12 hours. When possible, it should be
discussed with the patient or patient’s Authorized Representative if the patient lacks decision-
making capacity.
H. Required reconsideration of the No CPR Order when procedures are considered (surgery, invasive
diagnostic or therapeutic procedure)
i. A patient with a No CPR Order may undergo surgery, anesthesia, and/or invasive procedures that
carry some risk of cardiac arrest. No CPR Orders will not automatically be suspended for surgery,
anesthesia, and/or invasive procedures. Reconsideration of the patient’s DNR status is required
every time a procedure is proposed. Physicians involved in the patient’s care including the
attending physician should engage in a discussion with the patient or patient’s Authorized
Representative to discuss the patient’s goals for the procedure and preferences concerning
resuscitation.
ii. Any clarifications or modifications made to the No CPR Order should be documented in the clinical
record. All staff involved in the patient’s care should be aware of the overall plan of care with
respect to the No CPR Order, including the intraoperative/intraprocedure and
postoperative/postprocedure period. The patient or patient’s Authorized Representative may allow
the anesthesiologist and surgical/procedural team to use clinical judgment in determining which
procedures are appropriate in the context of the situation and the goals of care for the patient. If a
determination has been made to suspend the No CPR Order during the procedure, clear
documentation and communication about when or if the pre-existent No CPR Order will be
reinstated.
iii. In emergency situations it may be impossible or impractical for the surgeon, anesthesiologist or
proceduralist to speak with the patient or patient’s Authorized Representative. In such situations the
surgeon, anesthesiologist, or proceduralist must use his or her best judgment as to what the patient
would say regarding use of CPR during the procedure.
I. Admission of patients with valid Out of Hospital DNR orders.
i. If a patient is admitted with an existing Out of Hospital DNR Order in place that Order can be
honored until an inpatient No CPR Order is written. If the patient is going to continue have a No
CPR Order during hospitalization, this No CPR Order should be written within 12 hours of
admission. Staff shall not remove a patient’s Out of Hospital DNR wristband unless directed by the
patient or the patient’s healthcare agent or guardian to do so.
ii. In the unlikely event that a patient is admitted with an existing Out of Hospital DNR Order in place
and requests to be a full code while hospitalized, the patient’s wishes to be a full code should be
honored.

V. PROCEDURES FOR OUT OF HOSPITAL DNR ORDERS

A. An Out of Hospital DNR Order can be written only if all of the following conditions are met per Wisconsin
State Law:
i. The patient is at least 18 years of age.
ii. The patient has a terminal condition, or has a medical condition such that, were the person to suffer
cardiac arrest, resuscitation would be unsuccessful in restoring cardiac function, cause significant
physical pain or harm, or be successful only temporarily.
a. For Out of Hospital DNR Orders, a terminal condition is defined as an incurable condition


UW HEALTH CLINICAL POLICY 4
Policy Title: Do Not Resuscitate
Policy Number: 1.2.13


caused by injury or illness that reasonable medical judgment finds would cause death
imminently, so that the application of life-sustaining procedures serves only to postpone
the moment of death.
iii. The patient, guardian or healthcare agent requests the order.
iv. The patient, guardian or healthcare agent consents to the order after being provided written
information about the resuscitation procedures that the patient has chosen to forego and the
methods by which the patient may revoke the Out of Hospital DNR order. A Health Facts For You
(HFFY) entitled, “Out of Hospital No Code Orders” may be used for this purpose.
v. The order is in writing (Appendix - Emergency Care DNR Form and in the medical record).
vi. The patient, guardian or healthcare agent has signed the order.
vii. The physician does not know the patient to be pregnant.
B. After fulfilling the conditions above the attending physician or person directed by the attending physician
must:
i. Affix an Out of Hospital DNR wristband to the patient’s wrist, and
ii. Document in the patient’s medical record the medical condition that qualifies the patient for the Out
of Hospital DNR order, and
iii. Complete the Emergency Care DNR Form (available on the Wisconsin Department of Health
Services (DHS) website) and send to the Health Information Management (HIM) department to be
scanned into the patient’s medical record.
C. A patient must wear an Out of Hospital DNR wristband for the Out of Hospital DNR Order to be valid. A
patient without a bracelet will be presumed to have revoked the Out of Hospital DNR Order by removing the
bracelet. Out of Hospital DNR wristbands approved for use in Wisconsin:
i. Plastic Out of Hospital DNR wristband. The bracelet is required to be clear plastic and at least ¾
inches in width. It must contain a standardized insert, which will have preprinted in blue the words
Do Not Resuscitate and a logo of the State of Wisconsin. The required information must be printed
in size 10 or greater font and includes the patient’s name, address, date of birth, and gender on the
left half of the insert and the physician’s name, business telephone number, and signature on the
right half of the insert. At a minimum, bracelets will be available on the adult inpatient nursing units
and adult primary and pertinent specialty care clinics. Clinics that provide DNR bracelets will have a
designated person responsible for ordering State of Wisconsin inserts and plastic bracelets for their
clinic or clinic building.
ii. Metal Out of Hospital DNR wristband. StickyJ® Medical is the only recognized vendor of metal
Medical ID bracelets for the state of Wisconsin The metal bracelet displays the internationally
recognized symbol Staff of Aesculapius on the front and the words “Wisconsin Do Not Resuscitate
EMS” and the patient’s first and last name engraved on the back. The metal Out of Hospital DNR
bracelet may be purchased for a cost, through StickyJ® Medical. A paper order form is available.
a. Out of Hospital DNR wristbands purchased through Medic Alert prior to Wisconsin
identifying a new recommended vendor will continue to be recognized.
D. Revocation of Out of Hospital DNR Order.
i. A patient may revoke an Out of Hospital DNR order at any time by any of the following methods:
a. The patient, guardian or healthcare agent expresses the desire for resuscitation to
emergency personnel. The emergency personnel shall remove the Out of Hospital DNR
bracelet.
b. The patient defaces, burns, cuts, or other wise destroys the Out of Hospital DNR bracelet.
c. The patient removes the Out of Hospital DNR bracelet or another person, at the patient’s
request, removes the Out of Hospital DNR bracelet.
ii. The attending physician shall be notified of the patient’s revocation as soon as possible. The
revocation is effective regardless of when the attending physician has been notified. The revocation
will be documented in the patient’s medical record including the time, date and place of the
revocation, if known, and the time, date, and place, if different, that the attending physician was
notified of the revocation.

VI. FORMS

State of Wisconsin Department of Health Services, Emergency Care Do Not Resuscitate Order (DNR) Form

VII. COORDINATION

Author: Chair, Ethics Committee
Senior Management Sponsor: Chief Clinical Officer


UW HEALTH CLINICAL POLICY 5
Policy Title: Do Not Resuscitate
Policy Number: 1.2.13


Reviewers: Vice Chair, Ethics Committee; Director, Patient Relations; Director, Patient Resources; Director,
Risk Management; Corporate Counsel; Education and Development and Clinical Staff Education
Representatives; Chair, Resuscitation Review Committee; Co-Chair, Resuscitation Review Committee;
Pediatric Critical Care Medicine MD
Approval committees: Ethics Committee; Resuscitation Review Committee; UW Health Clinical Policy
Committee; Medical Board
UW Health Clinical Policy Committee Approval: March 20, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VIII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

IX. REFERENCES

Section 154 of the Wisconsin Statutes – Advanced Directives (Published December 10, 2015)
Wisconsin Department of Health Services, Do Not Resuscitate (DNR) Information (Last Revised: August 31,
2015). Retrieved from: www.dhs.wisconsin.gov
UWHC policy #4.17, Informed Consent
UWHC policy #8.25, Guidelines for Decisions to Limit Life-Sustaining Medical Treatment
UWHC policy #4.37, Advance Directives
UWMF policy, Advance Directives
Health Facts For You #5214, Out of Hospital “No Code” Orders
Health Facts For You #6162, Honoring a Patient’s Advance Directives

Aacharya RP, Maharjan RK. Ethical analysis of medical futility in cardiopulmonary resuscitation. J Clinic Res
Bioeth. 2014;5:3.
Ardagh M. Futility has no utility in resuscitation medicine. J Med Ethics. 2000;26:396-399.
Kasman D. When is medical treatment futile? J Gen Intern Med. 2004;19:1053-1056.
Tomlinson T, Brody H. Futility and the ethics of resuscitation. JAMA. 1990;264:1276-1280.

X. REVIEW DETAILS

Version: Original
Last Full Review: August 28, 2017
Next Revision Due: August 2020
Formerly Known as: UWHC policy #8.23, Do Not Resuscitate/No CPR Order; UWMF policy, Do Not
Resuscitate Order (DNR)