(A) The appendix of this rule shall constitute the do-not-resuscitate protocol for the state of Ohio.
(B) Under the protocol, a person can be a "DNR Comfort Care" patient or a "DNR Comfort Care-Arrest" patient. For a "DNR Comfort Care" patient, the DNR protocol is activated when a DNR order is issued or when a declaration that includes a directive that the declarant not receive CPR becomes effective under section 2133.03 of the Revised Code. For a "DNR Comfort Care-Arrest" patient, the DNR protocol is activated when the patient experiences cardiac or respiratory arrest.
(C) A "DNR Comfort Care-Arrest" patient is identified by the appropriate indication on the patient's DNR identification, as specified in rule 3701-62-04 of the Administrative Code, or if the patient does not have DNR identification, by a statement in the DNR order that the event of a cardiac arrest or a respiratory arrest, the patient is not to receive CPR.
Appendix A DNR Comfort Care
The State of Ohio Do-Not-Resuscitate Protocol Approved by the Ohio Department of Health
Patients can be either DNR Comfort Care patients or DNR Comfort Care-Arrest patients. The difference is that for a DNR Comfort Care patient, the State of Ohio DNR Protocol is activated immediately when a DNR order is issued or when a living will requesting no CPR becomes effective, but for a DNR Comfort Care-Arrest patient, the protocol is activated only when the patient experiences a cardiac arrest or a respiratory arrest. Be careful to check the patient's DNR order or DNR identification to determine which applies.
A DNR Comfort Care or DNR Comfort Care-Arrest patient's status is confirmed when the patient has one of the following:
1. A DNR Comfort Care card or form completed for the patient.
2. A completed State of Ohio living will (declaration) form that states that the patient does not want CPR (in the case of a patient who has been determined by two doctors to be in a terminal or permanently unconscious state).
3. A DNR Comfort Care necklace or bracelet bearing the DNR Comfort Care official logo.
4. A DNR order signed by the patient's attending physician or, when authorized by section 2133.211 of the Ohio Revised Code, a certified nurse practitioner (CNP) or clinical nurse specialist (CNS).
5. A verbal DNR order is issued by the patient's attending physician, CNP, or CNS.
Copies of these items are sufficient. EMS workers are not required to search a person to see if they have DNR Identification.
If an EMS or other health care worker discovers one of these items in the possession of a patient, the worker must make a reasonable effort to identify DNR patients in appropriate circumstances. Examples of ways to verify identify are:
* The patient or a family member, caregiver, or friend gives the patient's name.
* The health care worker knows the patient personally.
* Institution identification band.
* Driver's license, passport, or other picture ID.
If you cannot verify the identity of a patient with DNR Identification after reasonable efforts, you still should follow this protocol.
Verification of identity is not required for patients or residents of health care facilities when a DNR order is present on the person's chart.
EMS personnel who receive a verbal DNR order from a doctor or CNP/CNS must verify the identity of the person issuing the order. Some examples of verification are:
* Personal knowledge of the doctor/CNP/CNS.
* List of practitioners with other identifying information such as addresses.
* A return telephone call to verify information provided.
When this protocol is activated for a given DNR Comfort Care patient depends on whether the patient is a DNR Comfort Care patient or a DNR Comfort Care-Arrest patient. For a DNR Comfort Care patient, this protocol is activated when the DNR order is issued or the living will specifying no CPR becomes effective. For a DNR Comfort Care-Arrest patient, the protocol is activated when the patient experiences a cardiac arrest or a respiratory arrest.
"Cardiac arrest" means absence of a palpable pulse. "Respiratory arrest" means absence of spontaneous respirations or presence of agonal breathing.
For patients for whom the DNR Comfort Care protocol is activated, you:
* Suction the airway
* Administer oxygen
* Position for comfort
* Splint or immobilize
* Control bleeding
* Provide pain medication
* Provide emotional support
* Contact other appropriate health care providers such as hospice, home health, attending physician/CNP/CNS
* Administer chest compressions
* Insert artificial airway
* Administer resuscitative drugs
* Defibrillate or cardiovert
* Provide respiratory assistance (other than that listed above)
* Initiate resuscitative IV
* Initiate cardiac monitoring
If you have responded to an emergency situation by initiating any of the "will not" actions prior to confirming that the DNR Comfort Care Protocol must be activated, discontinue them when you activate the protocol. You may continue respiratory assistance, IV medications, etc., that have been part of the patient's ongoing course of treatment for an underlying disease.
Interaction with the Patient, Family, and Bystanders
The patient always may request resuscitation even if he or she is a DNR Comfort Care patient and this protocol has been activated. The request for resuscitation amounts to a revocation of DNR Comfort Care status.
If family or bystanders request or demand resuscitation for a person for whom the DNR Comfort Care Protocol has been activated, do not proceed with resuscitation. Provide comfort measures as outlined above and try to help the family understand the dying process and the patient's choice not to be resuscitated.
EMS or other health care personnel who implement the DNR Protocol for a DNR Comfort Care patient should document in their records, in accordance with the policy of their agency or facility:
* The item that identified the person as DNR Comfort Care (as listed in the Identification portion of this protocol).
* The method of verifying the person's identity, if any was found through reasonable efforts.
* Whether the person was a DNR Comfort Care or DNR Comfort Care-Arrest patient.
* The actions taken to implement the DNR Protocol.
When a DNR Order is Current
A DNR order for a patient of a health care facility shall be considered current in accordance with the facility's policy. A DNR order for a patient outside a health care facility shall be considered current unless discontinued by the patient's attending physician/CNP/CNS, or revoked by the patient. EMS personnel are not required to research whether a DNR order that appears to be current has been discontinued.
R.C. 119.032 review dates: 02/24/2009 and 02/24/2014
Promulgated Under: 119.03
Statutory Authority: 2133.25
Prior Effective Dates: 5/20/1999