In May 1999, Ohio enacted a do-not-resuscitate law and governing rules known as "DNR Comfort Care."
While DNR orders have been written by physicians for decades, the validity of DNR orders in some settings (e.g., a patient's home) and the transfer of DNR orders across settings (e.g. from a hospital to a nursing home) have been questioned. The "DNR Comfort Care" law remedies this uncertainty by creating a standard protocol and forms of identification that can be honored throughout Ohio.
Under Ohio law, the "DNR Comfort Care" protocol requires that professionals:
- WILL suction the airway, administer oxygen, position for comfort, splint or immobilize, control bleeding, provide pain medication, provide emotional support, and contact other appropriate providers; and
- WILL NOT administer chest compressions, insert an artificial airway, administer resuscitative drugs, defibrillate or cardiovert, provide respiratory assistance (other than suctioning the airway and administering oxygen), initiate resuscitative IV, or initiate cardiac monitoring.
Also, under Ohio law, two options for DNR orders are recognized, and Cleveland Clinic has established a third option. The three options are:
- DNR Comfort Care (DNRCC) orders permit comfort care only (the above protocol), both before and during a cardiac or respiratory arrest. This kind of order is generally appropriate for a patient with a terminal illness, short life expectancy or little chance of surviving CPR.
- DNR Comfort Care - Arrest (DNRCC-Arrest) orders permit the use of all resuscitative therapies before an arrest, but not during or after an arrest. A cardiac arrest is defined as an absence of palpable pulse. A respiratory arrest is defined as no spontaneous respirations or the presence of agonal breathing. Once an arrest is confirmed, all resuscitative efforts should be stopped and (following the above protocol) comfort care alone initiated.
- DNR - Specified orders allow the physician to "tailor" the DNR order to the specific circumstances and wishes of the patient. For example, under this option the physician could specify "pharmacological code only", or "no defibrillation", or "do not intubate".
Options 1 and 2 (DNRCC, and DNRCC - Arrest) can be made portable, i.e., under Ohio law they can travel with the patient from one care setting to another. Option 3 (DNR - Specified) is not portable.
Attention should be given to patients admitted or discharged with DNR orders so that all involved health professionals understand what kind of DNR order has been written. For patients admitted with a state-approved DNR order, the primary physician must reassess and rewrite the order to conform to Cleveland Clinic policy. If a patient survives to discharge, the DNR order should be rewritten in accord with patient wishes and according to state-approved options. Transport personnel and the receiving facility must be notified about the DNR order.
The Ohio DNR Comfort Care regulations permit various means of identification to communicate the patient's code status:
- a state-approved DNR Comfort Care form, signed by a physician or advanced practice nurse;
- a DNR necklace or bracelet;
- a DNR wallet card; or
- a Living Will specifying that a DNR order should be written when the Living Will becomes effective.
At Cleveland Clinic, all patients with a DNR order will wear a purple, hospital-style "alert" bracelet indicating that a DNR order has been written. A DNR Order form entitled End of Life Decision Making should be used for writing all hospital DNR orders. A patient brochure about DNR Comfort Care protocol is available. Prior to an invasive procedure and anesthesia, an existing DNR order should be reassessed, when possible, with the patient or surrogate. A Reassessment of Do Not Resuscitate Order During Invasive Procedures form should be completed by the ordering or primary staff physician.
