SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
                                              Columbia, South Carolina

OFFICE OF THE DIRECTOR OF MENTAL HEALTH           DIRECTIVE NO.   852-05
                                                                                                                                       (8-100)

TO:               ALL ORGANIZATIONAL  COMPONENTS

SUBJECT:    Do Not Resuscitate Orders

I.    Purpose

The purpose of this directive is to require each inpatient facility to develop a policy and procedure governing the entry of "Do Not Resuscitate" Orders, and to provide training to its staff concerning such policy and procedure.  This directive also sets forth standards and guidelines for the development of inpatient facility policies for the entry of "Do Not Resuscitate" Orders.

II.    Policy

It is the policy of the Department of Mental Health (Department) that its clinical staff receive regular training in Cardiopulmonary Resuscitation (CPR) and other resuscitative treatment, so that clinical staff are prepared to respond to emergencies in which a patient's respiratory or circulatory system has stopped.  It is also the policy of the Department that resuscitative treatment always be initiated for patients in the event of cardiac or respiratory arrest in the absence of a physician's "Do Not Resuscitate" order, unless the attending physician determines that resuscitative treatment would be futile.  It is also the policy of the Department to honor a competent patient's wishes to withhold unwanted medical care, including resuscitative treatment.  For those limited circumstances in which a patient will not benefit from resuscitative treatment, it is the policy of the Department to have standard procedures to govern the withholding of resuscitative treatment with the consent of a competent patient or the substitute decision-maker of an incompetent patient.

III.    Basic requirements for Facility "Do Not Resuscitate" Order Policy

    A.    Every inpatient facility will develop a written "Do Not Resuscitate" Order policy which includes the following features:

    1.   Definitions:   The policy will include the following definitions:

          (a)    Cardiac Arrest means the cessation of a functional heartbeat.

(b)    Cardiopulmonary Resuscitation or CPR means the use of artificial respirations to support restoration of functional breathing combined with closed chest massage to support restoration of a functional heart beat following cardiac arrest.

(c)    Clinical Staff   - For purposes of this Directive, clinical staff are those staff who provide direct clinical care to patients, such as physicians, nursing personnel, social workers and clinical counselors.

(d)     Competent Patient - An adult who has the ability to communicate and understand information and the ability to reason and deliberate sufficiently well about the choices involved.

(e)    Do Not Resuscitate Order - A written physician's order to suspend the otherwise automatic initiation of resuscitative treatment/cardiopulmonary resuscitation.

(f)    Incompetent Patient - An adult who is unable to appreciate the nature and implications of his condition, to make reasoned decisions concerning his care, or to communicate decisions concerning his care.  This incapacity must be verified by clinical assessment of the patient by two physicians, unless the individual was previously declared legally incompetent by Court order.

(g)    Respiratory Arrest (Pulmonary Arrest means cessation of functional breathing.

(h)    Substitute Decision-maker means the individual with priority under State law (The Adult Health Care Consent Act) authorized to make health care decisions on behalf of an adult who has been determined "unable to consent" (incompetent).

(i)    Resuscitative treatment means artificial stimulation of the cardiopulmonary systems of the human body, through either electrical, mechanical, or manual means including, but not limited to, cardiopulmonary resuscitation.

(j)    Terminal condition means an incurable or irreversible condition that within reasonable medical judgment could cause death within a reasonably short period of time if life sustaining procedures are not used.

(k)    Permanent unconsciousness means a medical diagnosis, consistent with accepted standards of medical practice, that a person is in a persistent vegetative state or some other irreversible condition in which the person has no neocortical functioning, but only involuntary vegetative or primitive reflex functions controlled by the brain stem.

    2.   General Procedures:  This policy will include the following general procedures governing the entry of "Do Not Resuscitate" Orders.

          (a)    Do Not Resuscitate Orders shall be written in accordance with this policy.

(b)    Determining the patient's competency, holding discussions with the patient or substitute decision-maker, and helping them to decide may require time that is not available in an emergency.  Therefore, a decision whether or not to write a Do Not Resuscitate Order should be made under conditions that permit consultation and reasoned decision.  Resuscitation procedure will be followed if a Do Not Resuscitate Order has not been entered.   

(c) The Do Not Resuscitate Order is the responsibility of the attending physician.  Only credentialed physicians who are members of the medical staff may write a Do Not Resuscitate Order.           

(d)     All Do Not Resuscitation Orders must be written.  No verbal or partial orders shall be given.  The order must be dated and signed.  The progress notes shall indicate the patient's competency and, if competent, his or her concurrence.  For an incompetent patient, unless the medical record contains a copy of a Court order declaring the patient legally incompetent, a Certification of Inability to Consent must be completed by two (2) physicians.  The progress notes shall then indicate discussion with, and concurrence by, the substitute decision maker.

(e)    When a Do Not Resuscitate Order is entered, the medical record should clearly reflect one of the following:

(f)    Physicians will promptly inform the charge nurse and, when possible others who are responsible for the patient's care, about the Do Not Resuscitate Order.  All who are responsible for the patient's care should understand the order and its implications.

(g)    If a patient is admitted or transferred from another facility within the Department of Mental Health with a Do Not Resuscitate Order, the receiving physician will confer with the patient, as soon as possible but no later than ten (10) days following admission and determine whether they concur with the continuation of the Do Not Resuscitate Order.  Until this procedure is accomplished the Do Not Resuscitate Order from the sending facility shall remain in effect.

(h)    A Do Not Resuscitate Orders will be reviewed with the patient or substitute decision-maker by the attending physician when there is a significant change in the patient's medical condition or upon the request of the patient or substitute decision-maker.

    3.        Resuscitation Decision for Competent Patients:  The policy will include the following guidelines for deciding upon the entry of a Do Not Resuscitate Order for competent patients.

(a)    The voluntary choice of a competent and informed patient will determine whether resuscitative treatment will be withheld.  This decision should be reached consensually between the attending physician and the patient.  The physician should note in the medical records the mental condition of the patient and circumstances which led to the decision to enter a Do Not Resuscitate Order.

A competent patient may request the entry of a Do Not Resuscitate Order at any time.  When the physician finds the patient's wishes to withhold resuscitation to be morally unacceptable or inappropriate and is unwilling to participate in the entry of the Do Not Resuscitate Order, he or she should transfer responsibility for the patient to another physician, or seek consultation regarding the patient's request.

(b)  A competent patient who requests or agrees to the entry of a Do Not Resuscitate Order always has the right to have such order withdrawn upon request.  If the competent patient later becomes incompetent, his or her decision made while competent should be respected.  For a competent patient, the consent of a substitute decision-make is not required.  Family disagreement with the decision of the patient is not a basis to override the patient's wishes or cause cancellation of the Do Not Resuscitate Order.  However, the family may be informed of the entry of a Do Not Resuscitate Order, unless the patient specifically requested that they not be so informed, and families should be informed of the facility's intention to abide by the wishes of the patient.

    4.    Resuscitation Decisions for Incompetent Patients:  The policy will include the following guidelines for deciding upon the entry of a Do Not Resuscitate Order for incompetent patients.

(a)   While competent, the patient may have anticipated the possibility of later incompetence and may have given explicit verbal or written instructions or advance directives regarding their desires or may have signed a declaration of a desire for a natural death (living will).  Such advance directives by patient while competent should be honored.  If such instructions or advance directives direct the withholding of resuscitative treatment in the current circumstances of the patient, the attending physician shall enter a Do Not Resuscitate Order in accordance with this policy.

(b)    In the absence of a determinative advance directive, the voluntary choice of the substitute decision-maker of an incompetent patient with a terminal condition or in a state of permanent unconsciousness will determine whether resuscitative treatment will be withheld.  An incompetent patient should be involved, however, in the decision concerning resuscitation treatment to the extent his or her capabilities allow.

(c)    In the event an incompetent patient with a terminal condition or in a state of permanent unconsciousness has no substitute decision-maker, available and willing to be consulted a Do Not Resuscitate Order may not be entered.

    5.    Futile Treatment:  The policy will include a paragraph indicating that the Department and its medical staff are not obligated to offer therapy or treatment that is clearly futile or medically inappropriate.  When a competent patient or a substitute decision-maker of an incompetent patient with a terminal condition or in a state of permanent unconsciousness objects to the entry of a Do Not Resuscitate Order, in circumstances which indicate resuscitative treatment is clearly futile, the physician may seek consultation with appropriate supervisory staff.  When there is agreement between the physician and the physician's supervisor that resuscitative treatment is futile or medically inappropriate, a Do Not Resuscitate Order may be entered after advising the patient or substitute decision-maker of the decision and giving the patient or substitute decision-maker the opportunity to transfer the patient to another health care facility.

    6.    Resolving Disagreements or Uncertainty:  The policy will provide a mechanism for assisting physicians, patients, substitute decision-makers and other concerned and involved family members and staff reach a consensus concerning a Do Not Resuscitate Order.

    7.    Transfer of Patient by EMS Personnel:   The policy will provide a paragraph which describes the provisions of the Emergency Medical Services (EMS) Do Not Resuscitate Order Act.

(a)    In the event EMS personnel are called to transport a patient of the facility, they cannot honor a Do Not Resuscitate Order except the one specifically authorized for, and directed to, EMS personnel.

(b)    In the event a patient of the facility has been diagnosed with a terminal condition, and the patient's medical record reflects the time, date and medical condition giving rise to the diagnosis, South Carolina law authorizes the entry of a specific EMS Do Not Resuscitate Order (a copy of which is attached as Appendix 1 of this Directive), with the consent of the patient or patient's substitute decision-maker.

(c)    In the event the attending physician of a patient with a diagnosed terminal condition has entered a Do Not Resuscitate Order for the patient and foresees the possibility of transferring the patient using EMS personnel, the physician shall consult with the patient, if competent, or the substitute decision-maker of an incompetent patient, concerning the entry of the EMS Do Not Resuscitate Order.

(d)    In the event an EMS Do Not Resuscitate Order is executed, it shall be placed in a location in the patient's record where it will be easily observed and readily available for delivery to EMS personnel in the event they are called to transport the patient.

(e)    An EMS Do Not Resuscitate Order is not a substitute for, but would be in addition to, a Do Not Resuscitate Order entered in accordance with this policy.

    8.    Staff Education:  The policy will provide for periodic efforts to educate and inform clinical staff concerning the facility's Do Not Resuscitate policy and related issues.

This Directive rescinds and replaces Directive No. 818-99, “Do Not Resuscitate Orders.”

May 5, 2005