National-Policy-and-Procedure-for-DNR-Status-EN

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NAT10NAL POLICY AND PROCEDIJRE FOR

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DO― NOTttRESUSCITATE(DNR)STATUS

Prepared by

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10NAL POLICY AND PROCFDURE FOR

DO―卜^￨}T‐

RESUSCITATE(DND STATUS WHEN MEAR.I ST()P SAUDI EEALTH COUNCIL

14Jumada I1 1438(13march 2017)

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Contents

⌒

1   3  DNR order declsion に

︐

7 8‑9‑10

9

5.

^DNR order during transfer

6

^Conflict resoluti<;n

-7.

_{lri lase of :ur89iy}

1  8 Wttmen with viable pregnancy

N R order ^revcrsa l/revlsron

10

cial circr.rrnstances

10

10

13‑14…

15

lntroduction

Methodology

Policy statement

l  DNR orderinitiatlon

1l Patlent′s rigl￢ts

References

1争 III

1壁 翌 1̲J

J u risprudence References

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INTRODUCTION:

Based cirr tire mission of the Saudi Health Council in coordinating between heaith sectors in ^Saudi Arabia to achieve in-rproved and enhanced health sen,ices provrded to citizens and residents. ^Due

to variability in policy and

procedure, concerrring cases

of

DO-NOT- RESUSCITATE (DNR) in lrosrlita!s of various health sectors. The Saudi Health Council deciCed in its sixty-fourth meeting

with

rescluticn ;rurnber 3/64 dated

Ll3lt434N

corresponding

to 1:

January 201,3

to

forrnulate c

l:rrnrnittce

:"ep:'esenting most of

the

health sectcrs in Saudi Arabia.

for thc

preDaraticn

of

the irational policv and procedure to unify the clinical aoplication of DNR rn SaudiArahia

METHODOLOGY:

Tl3

ccl':::lr:t:.itl i).rs re'.,rcweci

aii

DNR policies

and proceiures loiiowei in most cf tne

large irr.r-qpir:i,-

r-,i,-iriig,.:'ii

_!'realth

_sectors in

Saudi

Arabia. The cornmittee has also

reviewed :ir!er

ttlti'-,'t;i

1'1,ii'is-

:l:J

pt-ocedures, particulariy in Some ^hOSpitalS of North America, Europe and

i,1.;i;';;i;;

T:-!;: ,,;.,i;,,r)ai p,,..,iic! anci prncedlllr3 s/ds formitlated ia accordartco v'lith

tlte

prorrisions ol' i-,:;ii,r:.;o;y,

i'.;iii

an cntpl'asis on taking rnto account the Saudi patieilis and culiurai backgrounds anC sociol needs.

After

preparing

the

^initial

draft of the

policy and procedure,

it

was sent

for arbitration

ancj revision

to

distlnguished

group of

consultants and specialized doctors

in

the

referelce

h,-rspi'tals

of

most

of the

various health sectors in

the

Kingdom c-,f Saudi Arabia. The 14y{lil-ratoi; riiscir:lirres ir,cluded Coctors ^irr intensive care, and emergerrcy rnedicine and oncology.

Arter rhat v/c .ri,,Trff)crize

the

observations

of the

arbitratoi"s

of

doctors and the revision of the iriitial versir:n in

thc

iight of the fundamentai observations

that

convinced

the

members of the Ccrrimittee, After the conrpietion of the revised version cf

the

policy and orocedure,

it

has been aLrdited linguistically aird then translated into Arabic by ^King Abduilah !nstit-,-rte i'orTranslation and Arabization at lmar'n l\zlrrharnmad bin Saud lslamic University. Then it was sent in Arabic and English versions

to

a selected group

cf their

excellences' of judges and iawyers

for

opinioi'i, advice and legal legitirnacv.

ltwasaisosenttoHisExcellencythet\4ufti

ofSaudi Arabiofor"his consideration and tr-i i,.icge legitimate side and presented to the Standirrg Conrmittee for Fatwa. Then, in light

of

wl"rat is statecj in the referees and the words of guidance of the lvluftiand the Standing Committee

for

Fatwa nLrmber 37O2A1rc and the date

of

1411,111.437 H, the final changes

to the

^{policy and}

procedure was made

to

have

it

readyforapproval

bythe

Saudi health Council.

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DEFINIT10NS:

1.

2.

3.

6.

8.

CPR stands icr cardiopulmonary resuscitation, which refer to the ioilowing: intubation, bag- mask rrentilation, rnechanicai ventilatiorr, chest compression, administration

cf

rescue cardia; ano vasoa.trve mecications, cardioversion, and defibrrl lation.

DNR stands

for

do not resuscitate, which refer

to that,

in

the

event

of

a cardiac and/cr pulmcnary deterioratioir

ni

^airest, cardiopulmonary resuscitative rneasures r,viil

not

be initiated

Withholding,

in ti,is

dor-urrrent, refei"s

io

refraining

fronr

st.arting cardiopulrnonarv resuscitative measirres or declining of starting life support measures

Withdraw:ng,

rn this

Cocument,-

i'efers to ^stopping

cardropulrnonary r€,5us.itative

rtei:uies

o: !iie support nleasures.

Lirnite,.i

pscaicticr, in this

doc:urnent, refers

to

clinical guidance

setting out iirnits

[c app;op;'i;re trecLtrrent chorce:

fcr

patients approaching the en,J

cf

llfe, in the eve nt thev become acutely un'rveli.

Attending consultant, in thrs rlocurnqnt, refers to the most responsible physician ^(MRP) at the time and clinica! area'/\/hen the concerning decision ^is being macle

Physrcian, in this

do(unieirt, refer; to

arry rnedical doctor who lrolds vaiid registration irt

tire Saudi Commission

for

Heaith Specialties as a registrar/specialist.

Terrninally ill patient refer-s

to

a patient who is afflicted with a terrnina! illness. A ter'minei iilness is

a

iife-tirreatening cjisease

that

has reached

to a far

acivanced stage and will everrtually result in tl're death

of the

^patient regardless

of

any treatrnent intervention.

Surviva!

fcllowing

cardiopulmcnary i'esuscitative

efforts in

these patients

is

extremely unlikelv. Exai"npies of terminal illness rnay include (but are not linrited to): advanced-stage cancer

for which no

disease modifying options

are

available, irreversible multi-organ

failure,

inoperable malformations

that are

incompatible

with life, fatal

chromosomal anoma lies, and untreata ble advanced neurom ^uscula r diseases.

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POLICY STATEMENT:

1. Ever;r patient v;ili receive cardiopuimonary resuscitation and/or other appropriate resuscitative procedures _necessary

to

sustain

the patient's iife until the patient's

DNR

status

has been confirmed.

.:, The DNi{

order

is appropriately recomrnendeO when

the ^patient

is

terlninaily ill

and ^rvhen resuscitatioii measr,tre-s, in the Lrest j,"ir;!grnent of the attending consultant, would be ineffective at saving 1l're patient's life.

3. r c:- p.iLi3ri'-5 ,.ti:o are ;lreaciy adnritteo to a cr!ticai care unit, and have no response to aggressivc ::ie st.l(;:rtt't i:t:.cr'.'cntior^is, dfld

who

are assigrretl

a

Dl{R order,

the

attenrling consultant ^rr}ay

.o,-i,i.:ici-;rirl-,;rol;''- _-rnv further life;upport

rneasures;

withdrawing current life

support ,ilei)siii'r3,

oi

d.:'c.r:alaling, settirrg no fuiti-iei'escalation, or setting lrrnited escalation to the life- su;iainrtlg rr're.jSUI€s only when tlre burden on the pratient overly outweighs the expected benefit

ii(:ccii'cri,tg, tci'rhe 3-rhysician's best judgment.

,i. All

hos;-iii,pi5 recognize

ilrerr

r'espcnsioility

to crovide ethrcally

acceptable

care

while safegr:arci!rg the cultural, psychosocial, and religious values

of

each patient in accordance with sitaria law (lslarnic iaw). The primary _interest of

the

hospital is

to

sustain life while respecting a

p;tient's

wishes regarding dignity, respect, and comfort in the dying process. DNR orders shall by no rneai'is comp;'otnise

the

healthcare orovided

to the

^patient. Patients

with

DNR orders shall t.ontinue to ^r:eceive the highest possible quality of heaithcare, including palliative care, to maintain their comfort, dignity, and wellbeing until they'die.

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PROCEDURE:

1, DNR order initiation: The DNR order to be recornmended by THREE doctors ONE is the

atterlding physlcian as a consultant and the other TNA/C)doctors notless than specia‖sts.The three

ph、sl「ians rηlusi be vi/e‖ informed about the patlent′ s conditlon in orderto make a decision on the DNR statし

̀ of the t―^atien:′ and tlley should a‖

 sign the medical record of the patient tthe

retorr、 mendation s「lould include:

‐a)A brief description of the patientis medical conditlon′ supporting the terminal nature of the life thre3tenlng dise3じ 3.

b)Reference to any mё

dical consultatlons supportlng the decisittn of DNR.

c)RefertothediscussionsconcerningtheprognttsisorthedecisiononfDNRwiththepatient′

レiiS/heriariヽ ^:￨ソ■ign.flcant other or guardian

2 Conl,1lunic■

■●デ

,with patient/family:When appropriate or necessary′ the attending consultant

、″il:νけ:Lt.rtllソ_{￨ヽ l rì・} ^igil〕te one ofthe other TVψ O physicians signlng the DNR ordor)discuSS the

[,ヽRづtti、iol:ソ it卜 Li,■ l)aticnt and/C13n adult next of kin(or surrOgate decision―

maker)to infOrm

about the decision The approprlateness(Or Otherwise)of thiS COmmunicatlon ls the decision of the attending consultant whc knovvs the patient′ and the farnily may be in a better position to predict the patient′ s response to such dlscussion.

l DNR order decision: All i)￨く

R orders for a patlent must be documented and signed by the

,ttendlng consultant and t、vo other specialist physlcians(a tota1 0fthree)on the patlent′ s medical

「^ecord Mパ

th the DNR orderform

下ite Clrder rnav be initia‖ y giverl by telephone to his/her deSlgnee if the constJltantls not ava‖ able

iぅt the hospital′ in accoFdanCe vvith the existing telephone order procedure for general chnical

o「ders′ but such orders mtlst bc signed by the consultant vvithin 24 hours

4. DNR order va‖ dity:Ordcrs rnust be revlewed′ updated′ and clearly documented′ periodica‖ y一 at rllost every six rlnonths forinpatlents to reflect the changes in the patient′s conditlon′ if any.For outpatients′ tho most recent DNR(up t0 1 year)order lS in effect in any emergency situation′

unless changed by fuFther evalしlation lrl a‖ situatlons thls is done by three doctors one ls a consultant′ and the other two atleast speclalist A‖ sign the patientis record

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Saudi Health Council

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5. DNR order during transfer:upon or during transferrlng or receiving a patient to/fronl Other natlonal or lntornatlonal hcalth lnstitutes′ 5igned orders of DNR from otherfac‖ ities are valld for ,4 hours′ and a copy rrlusl accompany the patient ln this case′ the foHowing sh̀)lJld be■ ppliedi

a tthel卜atient′

s name MtJSttappear on the DNR orderform̀

ID lfstaffdiscoveFS tluring a cotit・ tll,t the patient possesses an order and deterrnines thto person

̲ is the〔)ne llamed on the DNR older′ the code should be stopped・

c ldentlty of the patient rnust be verified′ and the DNR order belongs to the patient uslng the

fOIIGV」 ing、〃ays:

￨(o mlnじ

nifat(ぃ

バ

th lhe patient ora family member orcare giver or his/herfttend to identiャ the patierlt

li「

̀〕

lTlrntinicat■ ヽり:ll・ ￨ゥne o「the rrledicaltear)nie「 ibers who knovvs the patient persOna‖ ^y.

11: The verification ofthe natlorialldentity oriq3ma Or any otheridentity vvith picture like the passport or driving license or equivalent.

、6. COnfl;cl resolutioniいノherl t1lcrc i3 diSagr̀〕 clment or confllct regarding tho DNR decision betNA/een .ine attOndlng consultant ano othcr physlcians′ a departmental chairperson or rnedical director

sケlall oe cor、sulted ln accordance、〃ith existlng procedures for resolvlng such conflict

7

ln ease

of

surgery:

lf

a patient _{lras a}

written

DNR order irr place prior

to

surgery,

the

urder is

aritomaticaliy reversed irr the cvent of surgery and automatically reactivated 48 hours after the sr;rp,ical procedure.

8. Women

with

viable pregnancy:

lf

a female patient has a

written

DNR order, in

the

case

of

^a

r,,rable pregnancy,

the

DNR

order

shall

be on hold until an

emergency cesarean

section

^is apprcoriately ^pe rformeci to save the baby.

9

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6;s3r-r.dl _6,e4aJl c!J5.4J ^I

Saudi Health Council 極 Ldi LLa y

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9.

DNR

order

reversal/revision:

l-he

DNR

order may be

reversed/ revised

by the

attending consultant according

to

the changes in

the

patient condition, in this case the following must be apr:lied'

a.

An order

to

reverse/rerrise

the

DNR

order

must be documented

in the ^patient's

medical record (DNR lj.orrn) by tire attending consultant.

b. Th,:,:rder

may be initialiy given by telephone

to

hisiher board certified designee

if

the i:r,.rnsuliant is

not

available

at the

hospital, in accordance

with

existing telephone orders for generai ciinicai orders, nut such orde15 must be signed by the attending consultant within 24 hours.

10. Special circumstances:

lf the patient record

^possesses

a

DNR

order and he/she

^{rs being} ti-ansferrcc

to

^a

ccnsuli;nt

who rs unwilling

or

unable

to

comply with the or,lei",

the

^{patient may}

bc iran:irt;'ied t.t;:ritoiner

corrsultant

who will honor the order, after

consulting

with

the i:it 'Jirir'i-,s niel ;haiip;-ri1.,!: Qt mediCal direCtOr.

J.i. raiierrt's i'ighf s: Tiir: DNiR order shall have no effect on other medicaUnur.sing care provlded by

lreoiiii ;;re

s[at{. Caie,,,ill be provided

to

maintain

the

patierrt's dignity, privacy, and ernotional anri religir:tis needs and nray include

but are not

limited

to:

sedation, analgesla,

fluid,

enteral feedirrg,, and personal ^hYgiene.

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References:

1. NationalGuard Health Af fairs Administrative Policy and Procedure, APP Number 1420-0i, Titled

"NO CODE STATUS", Dated May 2007, Rerrised January 201,2.

2. King Fahad Medical City Corpcrr^ate Policy and Procedure, CPP Number 1430-60, Titied "ALI-OW I'.IATURA!, l-)iATH ORDER", Dated

lluharram

3,1432 (28th November 2011)

3. King Fahad l\4edical City Corocrate Policy and Procedure, CPP Number I43?.t-09, Titled "END- OF-LIFE CARE", Dateo Rarnadarr 6,1,432 (6th August 2011,)

4. King FaisalSpecialist Hospitaland Research Center lnternal Polir:y and/or Procedure (lpp), lncjex I'Jumber MCO-NIC-ADN4-07-008. l'itled "Do Not

Attempt

Resuscitation (DNAR)", DaterJ

26

Safar 1,434

08

Ianuary ^.2013).

5 Kド

￢

g Knがid tJnivcrsily 1lospll,]I Polity Number HVVCPP‑046′  Titled 

′ ′ DO NOT

{[)NF)″

′ 「

)ate.メ Ottゥ

ber,o10̀Revised March 2012.

6.ト

ッ

li!:i3tl v(ヽfE吟Fせrlゞ

む

PTlic/3nd Prccedure′

丁

itled″

DO NOT RESUSCI丁

ATE〃

′

^Dated l 7 N/1avo Clinic DNR docurrlent N l′

′

vVlthholding Resuscitatlve Servlces for Patients

RESt」

SCITAT[

ヽ4ay 2012.

in a Non―ICU

⌒

Setting(DNR orDNR/DN1 0rdersi′

^′

8 Mayo clinic DNR docurrlent民 , Withholding and/cr Wlthdrawing Life SuppOrt″

9. Mayo f;lilni(・ DNR document N 3  ^″lA/thholding Resuscitative Services for Patients ln trle lcu Sc)tting(DIII′ IDNR or DNR/DNl orders〃.

10. VVlrral l」 niversity Teaci〕i rlg鋼 (,spital′ NHS Foilndatlon ttrust′

 

^∪K′

 Policy Number GP4′

 _lssue

∨ersion 3′ 丁^itled〃

DO NO丁 RFSUSOTATE POLICY(DNR)′ Dated August 2010

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J urisprudence References:

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*

_List

of

DNR

Taskforce Mernbers:

口瓦蓋 : す ^― ―― 一―

卜話高

「

―

1̲̲￨  ̲̲̲̲̲̲― ―

― ― ― ― 一 一 ― 一 ―

― 一 ――

―

― ― 十

一 一

―

―

一 一 ― ― ― ― ― ― ― ― ― ―

Title&Position

Professor of Family Medicine &

I Medical Education.

I Deao, college of rnedicine.

I General strpervisor of ^riredical

I Services

I President, Saudi Society for

I Studies in MedicalJurisprudence I UeaO of DNR Taskforce in Saudi

lfTTl,,Tlり 帥輛 eQに

Association(SICA) ￨

ぱ麻 ξ ∬島 ^{bn Abdubzレ}

Un〜erStty

i;;;;;il;-

I Sectior, Heacl, Nerrrocriticai Care i unit (trtccu)

I rne tntensive Care Department j King Abdulaziz Medical City

-

I aiyadh

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King Saud bin Abdulaziz tiniversity for Health

Health Affairs

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President advisor.

chairman of Saudi team

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Director, SRCA Center for international trauma life support ^(ITLS), chairman Saudi Arabia clrapter.

Director, SRCA CPR Trainrng ce ;tter

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Director SRCA Prehopital Trauma life support ^(PHTLS).

Director, SRCA Center of stroke, ACS, Al RWAY Management.

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Dr. Ayrnan Al Eyadhy

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Ministry of Education- King Saud University

King Saud University

Ministry of Health

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Director of acaclernic quality unit. Coltege of Medicine.

Chairman of lRB, health sciences college ;'esearcher of human subjects. King Saud Universitv

President of Saudi critical care society

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Dr. Mtrhammad Zafir Al Shehll

Dr. A;nani Al Kofide Dr Klialid AIsalcb

Dr. Salr;r ,\lsolai:ry

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Saud Univcrsity―

MEDICAL CITY KING KHALED UNIVERSTY HOSPITAL

Dr. Fai:;el l^l S*'aidan

Dr ZOHAIR Al.ASIRI

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Do Not Resuscitate ^(DNR.) Order Form

Note:

^{- This form} should be kept as THE FIRST SHEET in the Medical Record

- For further details regarding this form, ^please see the National DNR Policy and Procedure DIAGNOSiS(ES):

‐parlllTHEIAπEND:NGIPHYSiCiAN W:LL SELECTTHEIAPPROPR:ATE MANAGEMENTINTERVENT10N:

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Yes

No

Yes

No

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Call RRT/ICU

Admit tl tr

Non-invasive Ventilation

E tr Cardioversion n tr

lnotropes/VasopressorsE

tr Dialysis tr tr

Others(Pleasedescribe) JUSTIFiCAT:ON:

THREE S:GNATURES ARE REQU:RED FOR TH:S PART TO BE VAL:D(Attending Physician and two(2)otherS atleast specia!ist:

No. NAME HOSP:TAL:D

CONTACT#

SiGNATURE DATE T:ME

1

PAT:ENT OR FAMiLY MEMBER:NFORMEDiF APPROPR:ATE    (Eヨ Ves  □ No)

(NAME/RELATЮN/PHONE〉 ………・………

VERBAL ORDER NAME HOSP!TALID

CONTACT#

SIGNATURE DATE TIME

TAKEN BY WITNESS l WiTNESS 2

Part‖:THE DNR ORDER HAS13「 FN MOD:FiED TO THE FOLLOW:NG:

TO REVERSE OR REVISE THE DNR ORDER: Please place a diagonal line across part I of the form, write in large letters "VOID" _, and sign next, select the new code status by completing the following:

PLEASE SELECT THE APPROPRIATE MANAGEMENTINTERVENT10N:

□ Fu:!Code(CPR)̀」 メ^:び出iび岬^￨

□WiTHHOLDINGこ^Lり

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Yes

No

Yes

No El

^No

Call RRT/ICU

Admit D tr

Non-invasive Ventilation

I tr Cardioversion tr tr

lnotropes/VasopressorsD

I Dialysis tr tr

Others(Pleasedescribe) JuSTIFiCAT10N FOR REVERS10N OR REV:S10N:

S:GNATURE OF THE AΠ ENDiNG PHYSiCiAN IS REQUIRED:

NAME

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