The Virginia Board of Health recently published the final version of amendments to the Durable Do Not Resuscitate Order (Durable DNR) regulations. The revised regulations went into effect on July 20, 2011. All health care providers should be aware of the revised regulations and ensure that their policies and procedures comply with the new rules.
The revised regulations make a number of substantial changes to how DNR Orders are implemented and honored by incorporating a number of new definitions, allowing the limited use of different types of DNR Orders, allowing the use of legible photocopies of DNR Orders, and specifying that the standardized Durable DNR Order form will be available from the Office of Emergency Medical Services (EMS) website.
While the revised regulations encourage use of original Durable DNR Order forms, the new rules allow for copies of the goldenrod, standardized Durable DNR Order form to be used as an original. In addition, “Other DNR Orders” – such as those entered into at a nursing facility level that include the same information but omit a patient’s signature – may follow the patient between settings and be honored outside a health department licensed, behavioral health department licensed or state operated facility, all defined as a “qualified health care facility.” Thus, qualified health care personnel may honor a legible photocopy of a Durable DNR Form or Other Durable DNR Order inside or outside of a licensed hospital, nursing home, or correctional facility.
The new regulations specify that the standardized Durable DNR Order forms will be accessible via download from the Office of Emergency Medical Services (EMS) Website. Under the previous rules, health care providers could only obtain forms through a written request to the Office of EMS. The Office of EMS still needs to post revised information as of this date, but expects the new information and forms will be posted online in the beginning of August.
The new rules clarify that Durable DNR jewelry, such as a bracelet or necklace, may be honored in place of a Durable DNR Order. To obtain such jewelry, an original Durable DNR form must be provided to a vendor approved by the Virginia Office of EMS. Jewelry must contain the words “Do Not Resuscitate,” the ordering physician’s name and phone number, and the date the Durable DNR Order was issued.
The new rules expand and clarify the duties of physicians in issuing Durable DNR Orders. Physicians must now follow the process below in issuing Durable DNR orders:
The new rules also clarify how health care professionals should implement Durable DNR Orders by specifying the following order of procedures for implementing a Durable DNR Order:
For patients for whom a valid DNR Order is produced, the rules clarify the distinctions between resuscitative measures versus interventions intended to provide comfort care or alleviate pain. The new rules define cardiopulmonary resuscitation as the following procedures:
The Rules define procedures to provide comfort care or alleviate pain as the following:
If there is a misunderstanding with family members or others present at the patient’s location or if there are other concerns about following a DNR Order, the rules advise contacting the patient’s physician or EMS medical control for guidance.
The new rules simplify the process of revoking a Durable DNR Order by stating that if a patient expresses to a health care provider or practitioner the desire to be resuscitated in the event of a cardiac or respiratory arrest, such an expression shall revoke the practitioner’s authority to follow any type of DNR order. If the DNR order was executed upon the request of a patient, no one other than the patient has the authority to revoke a Durable DNR Order. If the patient is a minor or is otherwise incapable of making an informed decision and the Durable DNR Order was issued upon the request and with the consent of a person authorized to consent for the patient, then only that authorized person may revoke the Durable DNR Order.
Documentation requirements for Durable DNR Orders are also specified in the new rules. When following any type of DNR Order for a patient admitted to a licensed health care facility, health care personnel must document care rendered or withheld as required by facility policies and procedures. When following a Durable DNR Order or Other DNR Order for a patient who is not admitted to a licensed health care facility or who is in transit from a health care facility, the rules require qualified health care personnel to document the care rendered or withheld in the following manner:
All licensed health care providers should review their DNR order implementation policies and procedures to ensure they conform to the new rules. To avoid any issues, providers that interact with EMS units should coordinate with those units and other facilities. If your organization needs assistance in further interpreting the new rules or reviewing policies and procedures regarding Durable DNR Orders, please contact Peter Mellette (firstname.lastname@example.org), Harrison Gibbs (email@example.com), or Nathan Mortier (firstname.lastname@example.org). Mellette PC can be reached by phone at (757) 259-9200.