08/23/05 -- With more medically fragile children entering the public schools, local school boards are increasingly confronted with a vexing question: How do you respond to parents who bring school personnel an order not to resuscitate their child in a medical emergency?
It’s a challenging policy issue: For a family that’s agonized over this difficult medical decision, a school’s refusal to honor a do-not-resuscitate (DNR) order can be devastating. Yet, withholding emergency treatment from a child raises a host of medical, ethical, and legal considerations that school boards must weigh carefully.
“It’s difficult,” agrees Dr. Howard Taras, who helped develop the American Academy of Pediatrics’ policy statement on DNR orders in schools. “It’s one of those things where there’s never a great answer. What is right?”
This spring, Minnesota’s North St. Paul-Maplewood-Oakdale school board asked itself just that question when it reviewed a longstanding policy not to honor DNR orders.
Some board members expressed concern about the potential litigation if employees made a wrong decision. Some were disturbed by the idea of allowing a child to die on school grounds.
At least one board member, however, argued that fear of lawsuits should not deter a board from honoring a DNR order -- and that schools should be a partner with families facing serious health challenges.
In the end, the school board voted 5-2 to maintain its policy but did agree to allow school personnel to share any DNR order with paramedics who respond to a school emergency.
“It was an interesting discussion,” says board member Pam Cunningham, a registered nurse, who urged a change in policy. “It was a very heart-felt decision on everyone’s part.”
It’s unclear how many school boards refuse to honor DNR orders, but a review of policies nationwide reveals there are plenty of boards with a different perspective. The Bloomington, Minn., school district, for example, has honored DNR orders since 1998.
But Bloomington officials realize the import of that decision. Before any DNR order is honored, district policy requires an “individualized health care plan” be developed for the student with the involvement of parents, principal, classroom teachers, and other personnel.
“We need to be prepared,” says Pat Geraghty, the district’s executive director of student services. “The policy is pretty prescriptive. That prescriptiveness provides some structure that I think would help people deal with this sensitive issue.”
For school boards that have yet to confront this issue -- and those with new members who wish to revisit existing policies -- there are more difficult questions than easy answers.
One issue that pulls at the heartstrings is the impact on families when a DNR order is not accepted by the school, says Robert Nelson, a pediatrician at Children’s Hospital of Philadelphia. A terminally ill child could be saved by emergency care but left physically or mentally impaired -- a greater burden for the family and child.
He acknowledges that most school personnel are not trained to make medical decisions, but he suggests school boards could look harder to accommodate families. Reassigning a student to a school with a full-time nurse, for example, or providing specific medical training to school personnel might make a DNR.order workable.
But concerns about a medical error -- along with the liability risks involved -- prompted the Minnesota School Boards Association (MSBA) years ago to recommend its school boards refuse to honor DNR orders.
“One, you can’t undo the decision not to resuscitate,” says Cathy McIntyre, director of management and policy services for MSBA. “Two, those orders are directed at medical personnel, so we’re not sure they’re really appropriate for school personnel.”
In California, Taras works with a number of school districts that do not honor DNR orders -- and ask parents to sign a document acknowledging that fact. This information is important to pass along, he says, so parents understand the medical implications of sending their child to school.
“At least it’s understood,” he says. “That’s the important thing. We warn all our parents: We will resuscitate.”
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