C.M.R. 14, 191, ch. 3 - RULES REGARDING THE USE OF DO NOT RESUSCITATE (DNR) ORDERS IN DEPARTMENT INSTITUTIONS

PURPOSE:

The general policy of the Department of Mental Health and Mental Retardation is to provide the highest quality medical care to its patients with the objective of sustaining life and practicing medicine in conformity with highest ethical and medical standards. A standing order exists in all department institutions to initiate CPR* for patients in unanticipated need of resuscitation because CPR is often invaluable in the prevention of sudden, unexpected cardiac or respiratory arrest. For most patients, CPR should and is administered because there is a reasonable medical expectation of effecting a permanent or temporary cure of or relief from the illness or condition being treated. But the advisability of CPR cannot always be presumed. A Do Not Resuscitate ("DNR") order may be appropriate when, for example, resuscitation would be unsuccessful in restoring cardiac or respiratory function or when the prognosis of a patient is hopeless, death is expected as part of the natural course of the disease process and revival (resuscitation) from apparent death would only temporarily prolong the agonal state.

Every patient admitted to a department institution shall be presumed to consent to be resuscitated in the event of cardiac or respiratory arrest unless there is consent to the issuance of an order not to resuscitate as provided in these rules. A competent and informed adult patient has the right to direct the course of his own treatment, so be may decide, in conjunction with his physician, to have CPR withheld in the event of cardiac or respiratory arrest. An appropriate surrogate nay also choose to forego resuscitation on behalf of a dying incapacitated patient.

These rules set out standards under which an order to withhold CPR may be entered by an attending physician with the consent of a competent patient, or, in the case of an incapacitated patient, with the approval of an appropriate surrogate.

DEFINITIONS

"Terminal Condition" means a condition caused by injury, disease or illness from which, to a reasonable degree of medical certainty, there Is no recovery and which reasonably can be expected to cause death within one year.

"Medically contraindicated" means, to a reasonable degree of medical certainty, that CPR will be unsuccessful in restoring cardiac and respiratory function, or that the patient will experience repeated arrest in a short time period before death occurs or that CPR would impose unwarranted physical trauma on the patient in light of the patient's medical condition and the expected outcome of resuscitation for the patient.

*"CPR" is an abbreviation for cardiopulmonary resuscitation: a basic life support technique used to revive a patient when cardiac or respiratory arrest is detected. The procedure includes removing obstructions to the airway, attempting to restore breathing, and performing closed chest compression to restore the heart beat.

"Capacity" means the ability to understand and appreciate the nature and consequences of an order not to resuscitate, after having been provided with information regarding the risks, benefits and alternatives of such an order and the ability to make or communicate an informed decision with respect to resuscitation.

"Staff" means physicians and other health care providers employed by the department to provide care in department institutions.

"Attending physician" means the physician who has the primary responsibility at any given time for the treatment and care of a patient.

"Health care provider" means a person who is licensed, certified or otherwise authorized by the law of Maine to administer health care in the ordinary course of business or practice of a profession.

"Department institution(s)" means the Bangor Mental Health Institute, the Augusta Mental Health Institute, Pineland Center, the Aroostook Residential Center, and the Elizabeth Levinson Center.

"Medical Record" means the current and, where appropriate, permanent medical record of a patient.

"DNR order" means an order entered into the order sheet of the medical record of a patient signed and dated by the attending physician directing that no attempt be made by staff to resuscitate the patient should cardiac or respiratory arrest occur.

"Reasonably available" means that a person to be contacted can be contacted with diligent efforts by an attending physician or another person acting on behalf of the attending physician or the Institution.

POLICY :