Do-Not-Resuscitate Orders for Medically Fragile Students

Some school districts state that DNR orders and procedures are applicable to hospitals or other health care facilities but not schools. They cite the devastating effect a death at school has on the student body as a whole. Also there is fear that the school district could be liable for a "wrongful death" lawsuit if a student was left to die unaided. A large northeastern school district recently enacted a school policy requiring school staff to provide life-sustaining care to any child who needs it, regardless of parental orders to the contrary. (Reported in Education Week, December 13, l992.)

I have discussed this with the physician-director of our local EMS service. He states that "the EMS responders would take whatever resuscitative measures were necessary without having to decide about legal issues. They would begin resuscitation and continue until ordered to cease by their control physician. If a child at school has a DNR order, the nearest EMS unit should be notified as soon as the child is enrolled in school."

Other school districts have developed cooperative arrangements with the local emergency medical service (EMS) and the medical examiner's office. These districts call the EMS for children with DNR orders just as they would for all other children. When the EMS arrives, the situation is reviewed by EMS technicians who follow their medical director's advice.

In the Jan 27, 1993 issue of the New York Times, medical writer Janet Brody addresses the dilemma faced by health care workers, doctors, nurses, and emergency medical technicians, when faced with DNR orders. All are trained to save lives and are loath to let patients die.

Hospital and hospice workers have become accustomed to letting incurable, gravely ill patients slip away into expected death. School nurses and EMS technicians are faced with radically different types of patients and emergency situations. It will be difficult for them to follow a DNR order.

Questions arise:

1) if the child is not to be resuscitated, why call the EMS?

2) if life is hanging by such a fragile thread, why is such a child in school?

This is a situation that will have to be addressed individually, according to local and state law. Many parents have given serious thought to a DNR order for their severely medically fragile child and the law may be on their side. To not resuscitate is a new and frightening prospect for most school districts, but it is a situation that will eventually have to be faced. Nor have we heard the last of it.

The following Update will appear in Dec newsletter: - DNR Orders:

Renewed anxiety has awakened in schools following several law suits against school districts that failed to follow Do-not-resuscitate orders.

These orders from a student's parents and physician accompany some children with severe and profound developmental disabilities. They instruct the school to make no effort at resuscitating a child who appears to be dying, nor to call Emergency Medical Services.

School officials feel that children who are that fragile should not be in school. Parents may disagree, claiming that their child should be allowed to lead as normal a life as possible.

While hospitals and hospices have been comfortable for some time in carrying out DNR orders, school staff persons, including many nurses, oppose allowing a child to die at school without any effort to resuscitate. School nurses feel they are trained to support life rather than do nothing, while hospital nurses are more accustomed to dealing with death.

The school is faced with many complicated issues:
-The effect on other students: lack of a place to keep the body so students will not see a hearse come to the school during school hours. (Most emergency medical services do not transport bodies.)
-Who is designated to pronounce the child dead?
-Can a funeral parlor be called before the child is officially pronounced dead?

Nevertheless, there are some school districts that have arranged to carry out DNR orders. In one school where a child did die, the body was kept at school until school was out.

Nurses report that the attorney general of one state has ruled that the schools must follow DNR orders, while another state ruled that schools must not follow these orders. In one state, nurses were told by an official of their state board of nurse examiners that performing resuscitation despite written orders to the contrary could be considered an assault on the child.

The Texas legislature passed a law in the 1995 session, to go into effect Oct/Nov 1996, providing that out-of-hospital facilities must follow doctors' DNR orders. It is being widely construed that this includes schools. The law provides details about the format of the DNR order (student must wear alerting bracelet with DNR instructions)

The prevailing attitudes today bear some resemblance to the situation in the late 1970s after PL 94-142 required acceptance of severe and profoundly disabled students. Though it was then widely thought that caring for these children in standard public schools was an impossibility, procedures and facilities were gradually developed (at great cost) to accommodate them. It appears that DNR is headed down this same path, though at lesser cost unless a district is forced to pay for additional health care personnel. Eventually some state offices of education may take the lead in developing official guidelines for schools to follow. Though some states have convened task forces and have developed guidelines, none to my knowledge have been willing to publish them. Until such time as common procedures are developed, each district will have to develop their own.

Items to be included in developing a Protocol:
-Designate a place at school to hold the body temporarily.
-Notify the medical examiner's or coroner's office that a child with a DNR order is enrolled in school and prearrange with that office in case they need to send someone to the school to confirm death.
-Make arrangements with the local emergency medical service if they will agree to transport a body.
-Verify that the DNR order has been executed in proper compliance with any existing law, such as the child having to wear an identification bracelet.
-Arrange with the family which mortuary is to be called if parents cannot be reached. Arrange with mortuary to use a vehicle that does not resemble a hearse.

December, 1996