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Students with Comfort Care/Do Not Resuscitate Orders

To:School Nurses
School Physicians
From:Anne H. Sheetz
Director of School Health Services
Date:November 30, 2004

In response to requests from several Massachusetts school districts, the following guidelines for the care of students with Comfort Care/Do Not Resuscitate Orders were developed in consultation with the Massachusetts Department of Public Health (MDPH) Office of Emergency Medicine and the MDPH Legal Office. We hope these guidelines will assist you.

Children with "Do Not Resuscitate" or "Comfort Care" Orders in the School Setting

Children with terminal illnesses are attending school in increasing numbers. As the status of a child's health declines, a family may make the difficult decision not to prolong the child's life and request a "Do Not Resuscitate" order (DNR). A DNR order is executed by a physician, authorized nurse practitioner, or authorized physician assistant, with the consent of the parent or legal guardian, and issued according to the current standard of care.

If a child has a DNR order, a physician can submit a Comfort Care/DNR Order Verification to the Office of Emergency Medical Services in the Massachusetts Department of Public Health and obtain a Comfort Care form and an identifying bracelet. A Comfort Care identification (either the bracelet or the fully executed original form) is the only authorized way for pre-hospital emergency care providers (EMTs, first responders) to recognize a patient with a current, valid DNR order. EMTs and first responders called to a school will honor a DNR only if the child has a Comfort Care identification. Without a Comfort Care bracelet or original form, EMTs and other first responders who are called to a school will provide emergency treatment, including resuscitation, in accordance with standard EMS protocols, and transport to a hospital. The following website provides further information:

School districts should prepare a policy on the care of the child with a DNR order. Special consideration must be given to meeting child and family needs, as well as the needs of the students and staff. The child should be placed only in a school that has a full time school nurse. The local emergency medical services should be informed (with written permission from the parent or guardian) that there is a child in the specific building with a DNR/Comfort Care order

Respecting the family's wishes involves much pre-planning in the school setting. An individualized care plan should be developed with the family in collaboration with the child's physician and the school physician. It should include (a) how the child will be moved to the health room or other designated area if serious distress or death should occur at another location in the school; (b) what, if any, comfort measures should be given to the child; (c) protocols for notification of the family; and, if the child has died in school; (d) who will do the pronouncement of death (physician, nurse practitioner, or physician assistant)1; and (e) how the deceased will be removed from the school. This may involve planning with the family's designated funeral home and include such factors as type of vehicle, where it will park, who will clear the corridors, and what kind of stretcher or other method of transport will be used. (Please note: by law, EMS providers are not permitted to move the deceased.)

The plan should also address what will happen if the child is in distress, but does not appear to face an imminent risk of death. The response should include immediate consultation with the parents and, consistent with the plan, contact with the local EMS provider. If EMS is called, and the child has a Comfort Care bracelet or form, the EMT or first responder can provide comfort care and transport to a hospital. The type of care that EMS is able to provide in this situation is spelled out in the Comfort Care Protocol, available on the above-referenced website.

When a plan is in place, the school nurse should convey the plan to the appropriate school staff and administrators, answering any questions that they may have.

Whenever a death occurs in the school, the crisis team must be activated immediately to assist the family, staff and students to cope with the loss. Special consideration must be made for any students or staff who witness the death especially, if (per DNR orders) no treatment was performed either by school staff or EMS. Questions such as, "What if this happens to me?" and "Will they do anything for me?" may need to be addressed.


1 Nurse practitioner (NP) and physician assistant (PA) pronouncements function as "removal permits" thereby allowing the deceased to be removed from the school grounds by a funeral director. However the NP or PA who pronounces the death must (a) before the pronouncement, try to reach the attending doctor so that the doctor can declare the death and complete the death certificate, and (b) after the pronouncement, notify the attending doctor as to the location to which the body has been removed so that the physician can complete the death certificate. State law (M.G.L. Chapter 46, section 9) requires that a physician or the medical examiner complete the death certificate.

Last Updated: December 3, 2004

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