OHIO ADMINISTRATIVE CODE 3701-62 DNR ORDERS, IMMUNITY OF MEDICAL PROFESSIONALS Erik, Ashley, Robyn and Kecia
Background on DNR in Ohio In Ohio there are several legally recognized ways for you to give doctors and other health care providers instructions about the medical treatment you wish to receive (or do not wish to receive) before you actually need the care. 1.) Advance directives- such as living wills and health care powers of attorney. 2.) DNR Orders-a tool to help you and your physician with effective health care planning for the end of life that is planned out and signed beforehand.
DNR Orders in Ohio The Ohio Department of Health recognizes two different DNR order forms. A person, in consultation with a physician, certified nurse practitioner or clinical nurse specialist, may seek a DNR order. 1. A patient with a DNR Comfort Care-Arrest Order will receive all the appropriate medical treatment, including resuscitation, until the patient has a cardiac or pulmonary arrest, at which point only comfort care will be activated. 2. The broader DNR Comfort Care Order, says a patient may reject other life-sustaining measures such as drugs to correct abnormal heart rhythms. With this order, only comfort care would be provided until a point specified by the patient.
Why did Ohio adopt a law about DNR? Ohio's 1991 Living Will Law focused on patients in hospitals and nursing homes. There was uncertainty about the circumstances under which an emergency health care worker could act on a DNR order and honor a person's wish not to have CPR. In response to this the first DNR law in Ohio, 3701-62, was put into effect in 1999. The rules are authorized by Ohio Revised Code Sections 2133.21 through 2133.26. To accommodate changing medical technology, amendments must be made every five years.
1999 Ohio DNR Law The purpose of the 1999 DNR law is to help people communicate their wishes about resuscitation to medical personnel outside a hospital or nursing home setting. It allows emergency medical workers to honor patients' physician-written DNR orders even if they are at home rather than in the hospital when the heart or breathing stops. It protects emergency squads and other health care providers from liability if they follow their patients' DNR orders outside a hospital or nursing home setting.
Summary of Regulations A certified nurse practitioner (CNP) or a clinical nurse specialist (CNS) may take any action that an attending physician would take and also has the same immunity as a physician in this DNR rule.
Summary of Regulations The health care workers are not subject to any of the following arising out of or relating to the withholding or withdrawal of CPR from a person after DNR identification: Criminal prosecution Liability in damages for injury, death, or loss of personal property Professional disciplinary action
Summary of Regulations In the event that after DNR identification is discovered on the person but the person makes an oral or written request to receive CPR, the health care worker is not subject to any of the following: Criminal prosecution Liability in damages for injury, death, or loss of personal property Professional disciplinary action
Summary of Regulations In the event of an emergency and the EMS personnel or emergency department personnel provide CPR to a person who had a DNR order, the health care workers are not subject to the following: Criminal prosecution as a result of giving CPR Liability in damages or other civil action for injury, death, or loss of personal belongings Professional disciplinary action as a result of the provision of the CPR
Summary of Regulations There is no immunity to a health care worker who issues a DNR order that is contrary to reasonable medical standards or knows it is contrary to the patient s wishes or the patients medical power of attorney.
Summary of Regulations Standardized Items Approved as DNR Identification A DNR Order documented on a specific form issued by a physician A transparent hospital-type bracelet with an insert A necklace or bracelet with the DNR logo and the person s name Will include arrest under the logo if they are a DNR Comfort Care Arrest A wallet card
Summary of Regulations Eligibility to obtain DNR identification: Person has executed a declaration that authorizes the withholding or withdrawal of CPR The person s attending physician, CNP or CNS issues a current DNR order in accordance with the provided protocol AND has documented grounds for the order in their medical record.
Summary of Regulations A person may revoke their DNR identification or a DNR order by oral or written request or by: Destroying the DNR form or wallet card Permanently removing the DNR bracelet or necklace Revoking the declaration made to physician, CNS or CNP If EMS personnel are presented with DNR ID or orders, they should comply with the DNR protocol for that person
Summary of Regulations If a person possesses DNR ID and the attending health care worker or facility is unwilling or unable to comply with the protocol they should not delay or attempt to delay, the transfer of the person to a different facility or health care worker where the protocol will be followed
Summary of Regulations When a person is transferring from one facility to another, the transferring facility should notify the receiving facility of the patients DNR order The death of a person resulting from withholding or withdrawal of CPR based on the DNR order does not constitute a suicide, aggravated murder, murder, or homicide Nothing in this rule condones, authorizes, or approves of mercy killing, assisted suicide, or euthanasia
Summary of Regulations If the DNR is based on a valid declaration and if the declaration supersedes the durable power of attorney, the DNR supersedes the power of attorney. If the power of attorney supersedes the DNR declaration, the power of attorney supersedes the DNR
Summary of Regulations The possession of a DNR ID or order should not effect: Sale, procurement, issuance, or renewal of a life insurance or annuity Be forced to modify or invalidate the terms of any policy of life insurance or annuity Shall not impair or invalidate health insurance or other health care benefit
Economic Impact Specific immunity from criminal and civil action provided they follow the regulations. Possible lower overall health care costs? 30% of Medicare payments are for the 5% that die 40% of these expenditures occur in the last month of life However, evidence shows no effect of DNR orders on cost of care to the terminally ill, except: Among patients with DNR orders at the time of death, the cost was the least for those with DNR orders existing at admission and the highest for those with delayed DNR orders.
Social Impact Shifting attitude towards death & dying 90% want to die at home, 80% die in a hospital or other health care facility Providers and patients are unaware of the clinical effectiveness of CPR 15% survival rate after cardiac arrest 10-11% survival rate for patients over 65 3.5% survival rate for patients over 85 Greater need for patient-physician communication
Social Impact (continued) The patients who lacked an accurate understanding of DNR status were significantly more likely to perceive them as morally wrong. In a survey designed to characterize understanding of and beliefs about do-not-resuscitate (DNR) decisions and to identify dimensions of religiosity associated with moral beliefs about DNR decisions Gender, but not religious denomination, was significantly related to patients attitudes about the morality of DNR decisions.
Social Impact (continued)
Social Impact (continued) In a different survey of 200 medical inpatients, it was found that life support was desired in 90% of the patients if their health could be restored to its usual level 30% if they would be unable to care for themselves after hospital discharge 16% if their chance for recovery was hopeless 6% if they would remain in a vegetative state.
In other surveys of 139 respondents African-Americans (37%) and Hispanics (42%) compared to non-hispanic whites (14%) wanted their doctors to keep them alive regardless of how ill they were. of 14,008 hospitalized Medicare patients DNR orders were assigned to 11.6%. DNR orders were assigned more often to women and patients with dementia or incontinence were assigned less often to black patients, patients with Medicare insurance, and patients in rural hospitals
Discussion Questions More than DNR? Comfort Care Order for patient with ventilators When are physicians are forced to make DNR decisions? Comatose/Incompetent patients What if a patient changes their mind? Last minute revocations Unintended Consequences? Terri Schiavo
Sources Hamilton County Probate Court, http://www.ask.com/bar?q=dnr+orders+history+in+ ohio&page=1&qsrc=2417&ab=0&u=http%3a%2f %2Fwww.hamilton-co-probatect.org%2FDo%2520Not%2520Resuscitate. Ohio Department of Health, http://www.odh.ohio.gov/odhprograms/dspc/dnr/dn r1.aspx
Sources Garas N., Pantilat S. Advance Planning for End-of-Life Care. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. AHRQ. Retrieved 07/08/2009. http://www.ahrq.gov/clinic/ptsafety/chap49.htm Emanuel E., Emanuel L. The Economics of Dying The Illusion of Cost Savings at the End of Life. NEJM. 1994. Vol. 8 330:540-544 Maksoud A., Janhigen D., Skibinski C., Do Not Resuscitate Orders and the Cost of Death. Arch Intern Med. 1993. Vol. 153 10:1249 DeJong K., Sulmasy D., Gold K., Epstein A., Harper M., Eisenberg J., Schulman, K. The timing of do-not-resuscitate orders and hospital costs. J Gen Intern Med. 1999. Mar;14(3);190-192 Murray T. Don t Blame High-Cost, High-Tech Care at the End of Life for Rising Medical Costs. 1998. Robert Wood Johnson Foundation. Retrieved 07/08/2009. http://www.rwjf.org/about/product.jsp?id=16517 Beauchamp T., Childress J. Principles of Biomedical Ethics. 6 th ed. 2009. Oxford University Press. New York.
Sources Karnik AM. End-of-life issues and the do-notresuscitate order: who gives the order and what influences the decision? Chest 2002;121:683-6. Sullivan MA, Muskin PR, Feldman SJ, Haase E. Effects of Religiosity on Patients' Perceptions of Do- Not-Resuscitate Status. Psychosomatics 2004;45:119-28.