Do Not Attempt Resuscitation (Orders) in School
It is the position of the National Association of School Nurses (NASN) that schools and districts should establish DNAR policies, protocols, and practices that enable each 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. Each student with a Do Not Attempt Resuscitation (DNAR) order benefits from having an Individualized Healthcare Plan (IHP) and an Emergency Action Plan (EAP), developed by the registered professional school nurse (hereinafter referred to as school nurse). As professionals who bridge education and health and who advocate for students, school nurses work closely with school teams, families, and students’ healthcare providers to appropriately meet the special healthcare needs of students with a DNAR.
BACKGROUND AND RATIONALE
Growing populations of students with terminal, life-limiting, or incurable illnesses attend school full or part-time. Several federal statutes support the legal right for students with special healthcare needs to participate in school (Westbrook et al., 2020; Mikula, 2019). For some of these students, families may make the difficult decision, on behalf of their child or when appropriate, with their child, to withhold medical interventions that would be ineffective for sustaining life or if the risks of such treatment would outweigh the benefits. This decision requires a written medical order in the form of a DNAR document which specifies that attempts to resuscitate an individual using CPR should not be attempted when a person stops breathing or their heart stops beating (Selekman & Ness, 2019). Having a DNAR plan in place ensures that family preferences regarding medical treatment for their child are accommodated, should a medical crisis occur at school (Weiler et al., 2022; Mikula, 2019).
Depending on locale, other terminology with similar directives may be used in place of DNAR. These terms include Do Not Resuscitate (DNR), Allow Natural Death (AND), or Medical Orders for Life Sustaining Treatment (MOLST or POLST). For this position statement, the term DNAR is applied. In each case, these are medical orders, not legal documents, that are written by a primary care provider as permitted by state laws (physician, authorized nurse practitioner, or authorized physician assistant). The DNAR is one component of a broader healthcare plan encompassed within palliative healthcare and advanced care planning.
School nurses need to be aware of school district/local education agency (LEA) policies as well as local and state laws, regulations, and statutes that pertain to DNAR orders for students in schools (Weiler et al., 2022; Putman, 2017). The American Nurses Association (ANA) Center for Ethics and Human Rights states that “nurses are encouraged to take an active role in developing do-not-resuscitate policies within the institutions where they work” (2020, p. 4). School nurses, in collaboration with the LEA, can proactively advocate for and formulate clear, written policies and procedures for DNARs in schools that align with state laws and specific requirements.
Though it is not common for a student to die at school, if a student has a DNAR order, it is critical that the order becomes a part of the student school health record and that the DNAR order is incorporated into the student’s IHP at school (Weiler et al., 2022; Selekeman & Ness, 2019; Mikula, 2019). School nurses are exclusively responsible for the development, writing, and implementation of student healthcare plans (Yonkaitis & Shannon, 2019). IHPs for students with DNAR orders should specify comfort care provisions that may help to alleviate suffering. These therapeutic measures should address as appropriate, managing physical pain and symptoms and supporting the emotional, psychological, developmental, and spiritual needs of the student (Selekman & Ness, 2019; Mikula, 2019). Each IHP is a dynamic document that is adjusted as needed, according to the changing health status of the student. Under the direction of the school nurse, an IHP should be reviewed at least annually with the student's family and healthcare provider (Yonkaitis & Shannon, 2019). Because the DNAR is embedded as part of the IHP, the DNAR should also undergo review at the same time. The LEA should also conduct legal review of the DNAR simultaneously, for compliance with any changes in district policy or state regulations. Additionally, an EAP may be created to outline child-specific guidance and training requirements for non-medical educational staff so that they know how to respond appropriately to emergent needs of a student with a DNAR (Yonkaitis & Shannon, 2019; NASN, 2022). Together, these interventions help to ensure that students receive the best care possible while in school (Yonkaitis & Shannon, 2019; Westbrook et al., 2020).
Where there is a school nurse in school every day, all day, that individual can provide the ongoing expertise needed for in-school care and support of students with a DNAR order, as guided by the principles of the Framework for 21st Century School Nursing Practice (NASN, 2016; NASN, 2020). Through effective care coordination and communication, the school nurse facilitates accommodating the healthcare preferences of families and students, in collaboration with other healthcare providers, and plans school linkages with community resources and support systems such emergency medical responders that may be needed (Selekman & Ness, 2019; Mikula, 2019). School nurses enable informed and shared decision-making for students with a DNAR, with the goal of providing ethical, student-centered healthcare and the best possible quality of life for students.
ANA Center for Ethics and Human Rights (2020). Position statement: Nursing care and do-not-resuscitate (DNR) decisions. https://www.nursingworld.org/~494a87/globalassets/practiceandpolicy/nursing-excellence/ana-position-statements/social-causes-and-health-care/nursing-care-and-do-not-resuscitate-dnr-decisions-final-nursingworld.pdf
Mikula, L. (2019). School law alert: Honoring do not resuscitate orders. DiOrioSereniLLP. http://dioriosereni.com/school-law-alert-honoring-do-not-resuscitate-orders/
National Association of School Nurses. (2016). Framework for 21st century school nursing practice. NASN School Nurse, 31(1), 45-53. doi: 10.1177/1942602X15618644
National Association of School Nurses. (2020). Framework for 21st Century School Nursing Practice™: Clarifications and updated definitions. NASN School Nurse, 35(4), 225-233. doi: 10.1177/1942602x20928372
National Association of School Nurses. (2022). School nursing: Scope and standards of practice, 4th edition. National Association of School Nurses.
Putman, S. (2017). Do not attempt to resuscitate (DNAR) in the school setting. In C.A. Resha & V. L. Taliaferro (Eds.), Legal resource for school health services (pp. 243-252). SchoolNurse.com.
Selekman, J. & Ness, M. (2019). Students with chronic conditions. In J. Selekman, R. Shannon, & C. Yonkaitis (Eds.), School nursing: A comprehensive text (3rd ed., pp. 480‐499). F.A. Davis Company.
Westbrook, P., Weiler, S., & Birnbaum, M. (2020). Terminally ill students attending public schools: A legal analysis of DNR orders for P-12 students. West’s Education Law Reporter, 376(3), 864–869.
Weiler, S., Birnbaum, M., & Westbrook, P.(2022). An examination of state statutes and school district policies addressing minors with do not resuscitate orders. Educational Policy. Advance online publication. doi:10.1177/08959048221120278
Yonkaitis, C. & Shannon, R. (2019). Health and education plans for students with special healthcare needs. In J. Selekman, R. Shannon, & C. Yonkaitis (Eds.), School nursing: A comprehensive text (3rd ed., pp. 172‐199). F.A. Davis Company.
Acknowledgment of Authors:
Wendy A. Doremus, DNP, RN, FNP-BC (retired), PHNA-BC (retired)
Stacey Whitney, MSN, RN, NCSN
Clayton S. Wetzel III, BSN, RN, NCSN
Mary Nasuta, MS, BSN, RN, NCSN
Revised: June 2018, June 2023
Suggested citation: National Association of School Nurses. (2023). Do not attempt resuscitation (orders) in school (Position Statement). Silver Spring, MD: Author.
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.