SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Columbia, South Carolina
OFFICE OF THE
DIRECTOR OF MENTAL HEALTH
DIRECTIVE NO. 852-05
TO: ALL ORGANIZATIONAL COMPONENTS
SUBJECT: Do Not Resuscitate Orders
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
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"
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
(a) Cardiac Arrest means the cessation of a
(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
(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
(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
(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,
(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"
(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
(e) When a Do Not Resuscitate Order is entered, the medical record
should clearly reflect one of the following:
That the patient has a terminal condition, or
the patient is in a state of permanent unconsciousness, or
That although the patient has a condition for
which resuscitative treatment may be indicated in the event of
cardiac or respiratory arrest, the patient, while competent, gave
instructions to forego resuscitative treatment, or
The patient has a condition for which
resuscitation would, in the opinion of the attending physician, be
futile or medically inappropriate.
(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
(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
(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
May 5, 2005