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Policy 8.015
COMFORT CARE / DO NOT RESUSCITATE ORDERS
Marlborough Public Schools ensures that all students receive immediate first aid, including CPR, and activation of 911 emergency medical services (EMS) if they suffer a medically life-threatening event at school. An exception to this policy occurs when a student’s physician has issued a Comfort Care / Do Not Resuscitate (CC/DNR) Order Verification Form with the authorization of the child’s parent or guardian. School personnel must comply with this order and not begin resuscitation in the event of cardiac or respiratory arrest.
Children with terminal illnesses are attending school in increasing numbers. As the status of a child’s health declines, a family may make the difficult decision not to prolong the child’s life and request a DNR order. A DNR order is executed by an attending physician, authorized nurse practitioner, or authorized physician assistant, with the consent of the parent or legal guardian and issued according to the current standard of care. To assure ensure that a DNR order is recognized in any out-of-hospital setting (Marlborough Public Schools for this protocol), an attending physician, authorized nurse practitioner, or authorized physician assistant must provide a patient, who has a current DNR order, with a fully executed CC/DNR Order Verification Form. Pursuant to this protocol, Marlborough Public Schools personnel and EMS personnel will be instructed to honor a current valid CC/DDNR Order Verification Form. Either an original or a copy must be kept on file at the school in order to be honored by Marlborough Public Schools personnel or EMS personnel. Patients without a CC/DNR Order Verification Form will be resuscitated by Marlborough Public Schools personnel and EMS personnel in accordance with standard EMS protocols and be transported to a hospital. The type of care that EMS may provide in this situation is detailed in the protocols available here: https://mass.gov/lists/emergency-medical-services-statewide-treatment-protocols.
When CC/DNR is ordered by a physician, special consideration must be given to meeting the child’s and family’s needs, as well as the needs of the other students and staff. Respecting the family’s wishes involves extensive pre-planning in the school setting. The child should be placed only in a school that has a full-time school nurse. The local EMS should be informed (with written permission from the parent or guardian) that there is a child in a specific school building with a CC/DNR Order. An individualized care plan (ICP), including an emergency response plan, should be developed by the school personnel, including the school nurse, in collaboration with the family, the child’s physician, and the school physician.
The ICP should include, but not be limited to, the following:
- An original or copy of the CC/DNR Order Verification Form
- Contact numbers for parents/guardians
- Protocols for immediate notification of the parents/guardians/EMS
- Contact numbers for the ordering physician
- Notification to local EMS of the presence of a child in the school with a CC/DNR Order Verification Form
- What, if any, comfort care is permitted for the child
- How the child will be moved to the health room or other designated area if serious distress or death occurs at another location in the school
- Response to the child in distress, but not in immediate risk of death, including:
- Immediate notification/consultation with the parents
- Contact to local EMS
- If death occurs at school, identification of individuals to perform the pronouncement (e.g., school nurse, physician, nurse practitioner, physician’s assistant, medical examiner)
- How the deceased will be moved from the school.
- Immediate notification of the Crisis Team to assist the family, students, and staff.
- The CC/DNR Order Verification Form may be revoked at any time by:
- Physician and parent/guardian consent for cancellation or destruction of the CC/DNR Order Verification Form
- An oral statement, in person, by the parent/guardian that the student is to be resuscitated
Student confidentiality must be maintained. The parent/guardian has the ultimate authority to decide who is to be informed. The parent/guardian should be advised that anyone who is not directly informed about the CC/DNR Order would otherwise follow Marlborough Public Schools policy and initiate CPR.
The School Nurse Leader is to be informed when a school has received a CC/DNR Order Verification Form for a student. The School Nurse Leader, with written parent/guardian consent, will collaborate with the school nurse to convey the plan to the appropriate school staff and administrators, answering any questions that they may have. The school nurse is responsible for ensuring that all staff members who are informed of the CC/DNR Order are trained to follow the expected procedures.
A Medical Order for Life-Sustaining Treatment (MOLST) form may be used instead of a CC/DNR Order because the MOLST form can be filled out to indicate DNR if that is the patient’s decision. In some situations, a child may have both the MOLST and the CC/DNR forms. If both forms are present, in the event of cardiac or respiratory arrest, the most recent orders should be followed.
Approved 8/29/22