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PEDIATRICS Vol. 105 No. 4 April 2000, pp. 878-879
AMERICAN ACADEMY OF PEDIATRICS:
Do Not Resuscitate Orders in Schools
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ABSTRACT |
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Conclusion
Recommendation
References
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Increased medical knowledge and technology have led to the survival of many children who previously would have died of a variety of conditions. As these children with continuing life-threatening problems reach school age, families, professionals, and paraprofessionals have to deal with the challenges involved in their care. Some children may be at high risk of dying while in school. When families have chosen to limit resuscitative efforts, school officials should understand the medical, emotional, and legal issues involved.
In recent years, legal trends have expanded educational
opportunities, including access to adaptive technology and qualified classroom health aides, for children and adults with a wide variety of
disabilities or handicaps.1,2 The law provides that
children have access to education in the least restrictive environment
appropriate for their needs. The general thrust of legislation and
policy has been to integrate children with disabilities into regular
classrooms. Consequently, some children with chronic and terminal
conditions are at risk of dying while attending school. The American
Academy of Pediatrics (AAP) has previously addressed the ethical and
legal issues involved in decisions to either limit or withdraw
life-sustaining medical treatment.3 Parents who, after
consultation with their pediatrician and other advisors, decide to
forego cardiopulmonary resuscitation (CPR) of their child may want this
decision respected by school system personnel. These decisions
challenge all persons involved in a situation in which CPR may be given
to balance personal beliefs, strong feelings, legal concerns
(especially those having to do with liability), educational
considerations, and other issues.
A request for do not resuscitate (DNR) orders from a parent to
school system personnel may represent the parent's and in some cases
the child's wish for the school to recognize the stage of the child's
illness. A DNR order is not synonymous with abandonment of all medical
treatment and does not, of itself, rescind the obligations of the
health care team to provide quality care, such as suction, oxygen,
and pain medications. Rather, it is a dynamic part of the management
plan to be reviewed with the family.
Decisions to limit potentially lifesaving therapies typically
involve considerable emotional turmoil and careful deliberation about
the goals of treatment. The parents, their pediatrician and
consultants, religious advisors, and the child try to determine what
actions would further the best interests of the child. In many cases,
the decision-makers weigh the potential harm of intervention against
the potential benefit. For some children (for example, those with
muscular dystrophy with cardiac involvement), the risk of sudden death
attributable to arrhythmia may be considerable, and the likelihood that
resuscitation would be successful is small. In such cases, the patient
and family members may be especially concerned that resuscitative
efforts would cause physical pain and emotional suffering. The
experience for the child could be frightening and uncomfortable and
provide no anticipated benefit, such as returning a child to a quality
of life previously acceptable to the child and/or the family. These
children and their families may not wish the experience of treatment in
an intensive care unit that would not affect the underlying medical
problems.4
While competent adults have legislated alternative means to refuse
unwanted medical care, including advance directives, the options for
children have remained less well defined. Only a few states explicitly
authorize emergency medical services (EMS) to apply advance directives
to children. Although lacking explicit authorization, existing statutes
generally do not prohibit extensions of DNR orders for children to
out-of-hospital situations.5,6
In contrast, the school officials may be worried that a DNR order could
be misinterpreted by medically untrained staff, resulting in harm to a
child, or they may worry that personnel would feel bound not to respond
to an easily reversible condition, such as a mucous plug in a child
with a tracheostomy. Administrators have concerns about their personnel
responding to circumstances not anticipated by a DNR order, such as
when a child chokes on food or is injured. Officials are understandably
concerned that they and/or the school or school district could be held
liable if personnel failed to act in a way that might have prevented an
untoward death.
School officials may be rightfully concerned about the effect of a
death in school on other students. The parents of healthy children
may not want their children exposed to death in a classroom or other
school setting.7
Adversarial struggles between school personnel and family members
contribute little to the well-being of patients at risk of dying. It is
the intent of the AAP that its members respond to the changing needs of
their patients. It is also important that pediatricians become involved
in the process described here. While little case law, literature, or
precedent exists, it is important for pediatricians to be in the
forefront. All children deserve an education and are not only entitled
to be in the classroom as long as it remains in their best interests
but are guaranteed that right under Public Law 94-142, Education for
All Handicapped Children Act.1
With the increased numbers of children with chronic and terminal
diseases still able to attend school, it is important that pediatricians work with families and school personnel to provide guidance and advice that will continue a child's education and participation for as long as reasonable.
RATIONALE
CONSIDERATIONS
INTEREST OF OTHER STUDENTS
CONCLUSION
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RECOMMENDATIONS
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including nursing personnel, teachers, administrators, and EMS personnel, and, when appropriate, the child.
Individuals involved ideally will reach an agreement about the goals of
in-school medical interventions and the best means to implement those
goals. Concerted efforts to accommodate all points of view will help
avoid confrontation and possible litigation.
COMMITTEE ON SCHOOL HEALTH, 1999-2000
Howard L. Taras, MD, Chairperson
David A. Cimino, MD
Jane W. McGrath, MD
Robert D. Murray, MD
Wayne A. Yankus, MD
Thomas L. Young, MD
LIAISONS
Evan Pattishall III, MD
American School Health Association
Missy Fleming, PhD
American Medical Association
Maureen Glendon, RNCS, MSN, CRNP
National Association of Pediatric Nurse Associates and Practitioners
Lois Harrison-Jones, EdD
American Association of School Administrators
Linda Wolfe, RN, BSN, Med, CSN
National Association of School Nurses
Jerald L. Newberry, Executive Director
National Education Association, Health Information Network
Mary Vernon, MD, MPH
Centers for Disease Control and Prevention
COMMITTEE ON BIOETHICS, 1999-2000
Robert M. Nelson, MD, PhD, Chairperson
Jeffrey R. Botkin, MD, MPH
Eric D. Kodish, MD
Marcia Levetown, MD
John T. Truman, MD
Benjamin S. Wilfond, MD
LIAISONS
Alessandra (Sandi) Kazura, MD
American Academy of Child and Adolescent Psychiatry
Peter A. Schwartz, MD
American College of Obstetricians and Gynecologists
Ernest F. Krug III, MD
American Board of Pediatrics
SECTION LIAISONS
Donna A. Caniano, MD
Section on Surgery
G. Kevin Donovan, MD, MLA
Section on Bioethics
LEGAL CONSULTANT
Dena S. Davis, JD, PhD
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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AAP, American Academy of Pediatrics; CPR, cardiopulmonary resuscitation; DNR, do not resuscitate; EMS, emergency medical services.
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REFERENCES |
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- Education for All Handicapped Children Act, 20 USC. 1400 et seq
- Americans with Disabilities Act of 1990, 42 USC. 12101 et seq
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American Academy of Pediatrics, Committee on Bioethics
Guidelines on foregoing life-sustaining medical treatment.
Pediatrics
1994;
93:532-536
[Abstract/Free Full Text] - Rushton CH, Will JC, Murray MG To honor and obey: DNR orders and the school. Pediatr Nurs 1994; 20:581-585 [Medline]
- Scofield GR A lawyer responds: a student's right to forgo CPR. Kennedy Inst Ethics J 1992; 2:4-12 [Medline]
- Younger SJ A physician/ethicist responds: a student's rights are not so simple. Kennedy Inst Ethics J 1992; 2:13-18 [Medline]
- Strike KA An educator responds: a school's interest in denying the request. Kennedy Inst Ethics J 1992; 2:19-23 [Medline]
Pediatrics (ISSN 0031 4005). Copyright ©2000 by the American Academy of Pediatrics
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