Policy 8655: Student Do Not Resuscitate Procedure (Rules)

Definitions 

1. Attending Physician – means the physician who has primary responsibility for the treatment and care of a declarant.
2. Declarant – means a person who has executed a do-not-resuscitate order on his or her own behalf (student 18 years or older), or on whose behalf a do-notresuscitate order has been executed pursuant to applicable laws.
3. Do-Not-Resuscitate order – means a document executed under Public Act 193 of 1996, as amended, directing that if an individual suffers cessation of both spontaneous respiration and circulation in a setting outside of a hospital, resuscitation will NOT be initiated.
4. Do-Not-Resuscitate Identification Bracelet or Identification Bracelet – means a wrist bracelet that meets the requirements of Act 193 and worn by a declarant while a do-not-resuscitate order is in effect. The identification bracelet shall be imprinted with the words “DO-NOT-RESUSCITATE ORDER”, the name and address of the declarant, and the name and telephone number of the declarant's attending physician, if any.
5. Guardian –means a person who has qualified as a guardian of a minor or a legally incapacitated individual under a parental or spousal nomination or a court appointment and includes a limited guardian as described in sections 5205, 5206, and 5306 “of the estates and protected individuals code, 1998 PA 386, MCL 700.1104(l)”.
6. Order – means a do-not-resuscitate order.
7. Patient Advocate – means an individual designated to make medical treatment decisions for a patient under Section 5506 to 5515 of the estates and protected individuals code, 1998 PA 386, MCL 700.5506 to 700.5515.
8. Vital Sign – means a pulse or evidence of respiration. 

Written Request 

A parent/guardian, declarant (e.g., a student 18 years or older), or patient advocate may request in writing a Do-Not-Resuscitate order for their District student. The completed Do-Not-Resuscitate order shall be provided to the principal. The principal shall provide a copy of the order to the school nurse. 

Requests for Do-Not-Resuscitate procedures must be signed and authorized by the parent(s) with legal decision-making authority. If the parent shares legal decision-making authority according to a court order regarding education or medical determinations, both parents of the minor child must execute the order (e.g., joint legal custody situations). 

Do-Not-Resuscitate Identification Bracelet or Identification Bracelet 

A Do-Not-Resuscitate Identification Bracelet is recommended, but not required. 

Physician Orders 

Request by parents for Do-Not-Resuscitate orders must be supported by medical orders from a physician licensed in Michigan. The medical orders must include the full name of the District student, the parent’s/guardian’s full name(s), the student’s birth date, medical diagnosis and prognosis. The medical orders should contain information that describes care to be provided and state that the physician fully supports the request of the parents/guardians that no resuscitative measures will be taken. (See Appendix 1for an example.)

Individualized Healthcare Plan 

The District nurse shall develop an Individualized Healthcare Plan with input from attending physician and parent/guardian, declarant, or patient advocate. 

Release of Liability 

A Release of Liability form will be signed by parent/guardian, declarant, or patient advocate (See Appendix 2) 

Revocation 

A parent/guardian, declarant, patient advocate, or attending physician may at any time revoke a Do-Not-Resuscitate order. Requests to revoke should be written; however, the order may be revoked verbally if two District staff are present and record the date and time of the verbal revocation in writing. If this is a joint custody situation, both parents must provide the verbal authorization. If a previously approved Do-Not-Resuscitate order has been rescinded or revoked, District staff shall write, “Discontinued,” in black marker across the revoked written instructions or Do-Not-Resuscitate order. The principal and school nurse are jointly responsible for informing appropriate School District personnel that the Do-Not-Resuscitate order has been rescinded. The school nurse will revise the Individualized Healthcare Plan to reflect the change in the student’s current needs. Once a previously approved Do-Not-Resuscitate order has been revoked, it may not be reinstated unless the entire process is initiated from the beginning and completed. 

Procedure 

Once the District is provided with a properly executed Do-Not-Resuscitate order, the following actions are required:

• If a Do-Not-Resuscitate order form is presented and is not substantially in the form as outlined in Appendix 1, or is not complete and signed by all parties, resuscitation will be initiated while EMS is activated.
• Upon receipt of a valid Do-Not-Resuscitate order, the principal will provide actual notice of the Do-Not-Resuscitate order, or revocation, to each teacher and other persons who provides the student with instructional or noninstructional services.
• The District student’s valid Do-Not-Resuscitate order will be stored in the student’s cumulative record.
• District employees shall not attempt resuscitation of any student who meets all of the following criteria:
  1. District student has a valid Do-Not-Resuscitate order (the student may or may not be wearing a Do-Not-Resuscitate bracelet).
  2. Student has no vital signs. This means no pulse or evidence of respiration.
• District employees shall attempt resuscitation of any student who meets all of the following criteria:
  1. District student has a valid Do-Not-Resuscitate order (The student may or may not be wearing a Do-Not-Resuscitate bracelet).
  2. Student has vital signs. This means they have a pulse and respirations.
• District employees shall attempt resuscitation of any student who does not have a valid Do-Not-Resuscitate order.
• In the event care has been initiated on a student, and subsequently a valid DoNot-Resuscitate order form is identified, and the student meets the criteria in Item 1 above, resuscitation shall be discontinued.
• A Do-Not-Resuscitate order will not be followed if the declarant, guardian or patient advocate revokes the order. Resuscitation efforts will be initiated, and EMS will be activated.