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Planning for DNAR Orders

Emergency Intervention, Health Office Management

 

Considerations and Planning Related to the Decision to Honor a Student’s Request Do Not Attempt Resuscitation (DNAR) Order

Although a child may have a health condition, in which death is anticipated in the near future, attending school may be particularly important for the student. It allows them to have a sense of normalcy and an opportunity to engage with friends and school staff. With the increase in school attendance of children with complex medical needs, including students with terminal illnesses, it is imperative that school districts establish policies related to how they will respond to requests for Do-Not-Attempt-Resuscitation (DNAR) from families and physicians. The American Academy of Pediatrics (AAP) (2010) believes, “it is ethically acceptable to forego Cardiopulmonary Resuscitation (CPR) when it is unlikely to be effective or when the risks outweigh the benefits, including the parents’ and child’s assessment of the child’s quality of life” (p. 1073).

If a school district’s policy will allow the DNAR order to be honored, the school district administration and school staff must work together with the student, family, health care providers and others to develop policies, protocols, and practices that enable the “student to receive best practice care, as designated by clear and specific directives for the individual, throughout the entire course of their condition while they are in school” (National Association of School Nurses (NASN), 2023, p.1).

If the school district’s policy is to not honor the student’s DNAR order and the student does not currently have an Individualized Health Care Plan (IHCP) and/or Emergency Action Plan (EAP), then the school nurse should develop a plan that outlines the actions that should be taken in response to a life-threatening emergency.

The following document contains a list of things that the school district should consider when developing policies, procedures, and protocols related to honoring a student’s DNAR request.

Important Considerations:

  • DNAR orders are physician orders, in contrast to patient directives. So, a written order from a physician is required for DNAR to be considered.
  • Although staff may feel like they are “doing nothing” in response to a student’s life-threatening situation, “DNAR orders are not orders to “do nothing,” nor do they represent a decrease in the quality or intensity of care” (AAP, 2010, p. 1073). The student’s Individualized Health Care Plan (IHCP) should indicate what action steps the school nurse or school staff should take in response to a life-threatening situation. This could include providing comfort measures, holding the student, and/or providing supplemental oxygen. For more information see the IHCP section below.
  • The DNAR order directs lay people trained in CPR to forgo performing CPR in the case of a respiratory or cardiac arrest, regardless of the cause. Parents and the student, if appropriate, need to acknowledge these realities as part of their permission and assent (AAP, 2010).
  • Through national discussion on the issue of DNAR orders in schools, some have expressed concern regarding how other students will respond to school staff withholding CPR on a student. The implementation of DNAR requests in schools is not, however, the only situation that may cause distress for bystanders. Witnessing unsuccessful CPR may also be traumatic (AAP, 2010, p. 1075).
    • A school’s emergency response plan should include actions to take to immediately remove bystanders from an emergency situation.

Action Steps School Districts Should Take If Implementing DNAR Orders

Multidisciplinary Team

  • School districts should develop a multidisciplinary team that will work with the student, the family, and the student’s health care team, and district legal in response to a DNAR order.
  • The school district’s legal representative should review all applicable state statutes, regulations, judicial or other decisions, or state attorney general opinions to determine if there are any legal reasons the DNAR order should not be honored.
  • The multidisciplinary team should review the DNAR order to ensure that all aspects of what care should and should not be provided are clear and understood.
  • The multidisciplinary team should discuss whether anyone has reason to believe the parent/guardian is making the DNAR request, lacks the authority to do so, has ulterior motives, or that the decision is not in the best interest of the student.
  • The multidisciplinary team should collaborate with local Emergency Medical Services (EMS) providers, health care provider(s), medical examiner, and funeral home.
  • The multidisciplinary team should determine which parties require a copy of the DNAR order (EMS).
  • The multidisciplinary team should clarify what care EMS is able to provide.
  • The multidisciplinary team should inform staff about the liability that staff could face for following/not following the student’s DNAR order.
  • The multidisciplinary team should create a plan for how to assist the school community in the event of the student’s death.
  • If the school does not have a full-time school nurse, the multidisciplinary team should evaluate whether a full-time school nurse or one-on-one nurse is needed for the student.
  • The multidisciplinary team should talk with staff members to determine if they have personal beliefs or moral obligations that would prevent them from following any of the DNAR order procedures.
  • The multidisciplinary team should establish a system of communicating with the school’s medical emergency response team (MERT) so that everyone understands the appropriate responses for this student
  • Should establish a plan if there is a sibling in the same building as the student.
  • Given the complexity of implementing a DNAR order, if needed, the multidisciplinary team should consider periodically conducting a drill or tabletop exercise.

School Nurse

  • The school nurse should develop an Emergency Action Plan (EAP) in collaboration with the multidisciplinary team.
  • The EAP should outline the child’s needs and provide specific directives for the staff to follow in the event of a cardiac or respiratory arrest and/or other life-threatening emergency. The elements of the plan should include:
  • Describe specific steps school staff should take in the event that the student experiences cardiac or respiratory arrest or some other life-threatening emergency.
    • The plan should identify which staff will be involved in the response.
    • The plan should clearly identify what actions should be taken and what actions are not allowed.
      • It may be difficult for lay people to identify symptoms that are associated with the student’s underlying health condition that warrant treatment versus symptoms that indicate cardiac or respiratory failure and imminent death. The multidisciplinary team should decide if a school nurse or one-on-one nurse should be present in the building at all times.
    • The plan should clearly identify who is authorized to perform which actions/procedures.
    • The plan should clearly identify what steps should be taken if the student is in distress, but imminent death is not expected:
      • EMS consultation
      • Consultation with parents/guardian
      • Transportation to hospital (hospital of choice vs. nearest hospital needs to be discussed).
  • The location to which the child will be moved if serious distress or sudden death should occur at school or plans to remove onlookers from the area if the child cannot be moved.
  • The comfort measures that should be offered to the child.
  • Protocols for notification of the prearranged EMS provider.
  • Protocols for notification of the family.
  • Protocols for notification of the primary care physician.
  • Protocols that define steps to take should the child die in school.
  • Designation of the clinician who will pronounce the child’s death (physician, nurse practitioner, or physician assistant).
  • A specific plan for removing the body from the school to a local health care facility or designated funeral home, including such details as the type of vehicle to be used, where it will park at the school, who will clear the corridors, and what kind of transport equipment will be required to move the body to the waiting vehicle.
  • Once the EAP has been developed the parents, school administration, school nurse, physician, and student, if applicable, should sign the plan to acknowledge that they understand and agree to the plan.
  • In collaboration with the multidisciplinary team, the school nurse should review and update the EAP whenever the student’s condition changes, at least annually.
  • In addition to the EAP, the school nurse should develop an Individualized Health Care Plan (IHCP).
  • The school nurse should set up communication plans with:
    • All members of the student’s health care team, including palliative care and hospice, as applicable 
    • Local EMS
    • Funeral director
    • Involved local agencies, others as needed

Documentation

  • Obtain DNAR order.
  • Obtain releases of information for health care provider(s), EMS, medical examiner, funeral home, and other agencies as needed.
  • DNAR order should have an expiration date.
  • For students 18 years or older, obtain student permission for DNAR.
  • Have the student obtain an out of hospital DNAR bracelet, if required.

Education and Training

  • All those who have regular contact with the student (including individuals who provide transportation for the student (i.e., bus driver)) should be informed of the DNAR order and what actions they are to take if the student were to experience a life-threatening emergency.
    • Additional education and training should be provided if the student’s condition were to change, or changes were made to the DNAR order.
  • The multidisciplinary team should identify, in consultation with the student and family, what information should be provided to other students regarding the student’s condition and the presence of a DNAR order.

Resources

References

Adelman, J. (2010). The school-based do-no-resuscitate-order. DePaul Journal of Health Care Law, 13(2), 197-215.

American Academy of Pediatrics. (2010). Policy statement—Honoring do-not-attempt resuscitation requests in schools.

American Academy of Pediatrics. (2019). Managing chronic health needs in child care and schools. A quick reference guide, 2nd Edition. Itasca, IL: Author.

Deutch, J.M., Martin, L.G., & Mueller, J.A. (2015). Managing students with health issues: Section 504 plans, dnr orders, and contagious diseases.

Hodges, Loizzi, Eisenhammer, Rodick & Kohn, LLC. (2015). Do not resuscitate (DNR) orders: A checklist for school districts.

National Association of School Nurses. (2023). Do not attempt resuscitation (orders) in school (Position Statement). Author.

Selekman, J. & Ness, M. (2019). Students with chronic conditions. In J. Selekman, R. A. Shannon, & C. F. Yonkaitis (Eds.). School nursing a comprehensive text. (3rd ed., p. 496). (Philadelphia, PA: F. A. Davis Company.

Zacharski, S., Minchella, L., Gomez, S., Grogan, S., Porter, S., & Robarge, D. (2013). Do not attempt resuscitation (DNAR) orders in school settings: special needs school nurses review current research and issues. NASN School Nurse (Print), 28(2), 71–75.

Acknowledgement of Reviewers

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing

Updated 04/18/2025

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