Code of Maine Rules › 14 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 191 - MENTAL HEALTH AND MENTAL RETARDATION - GENERAL › Chapter 3 - RULES REGARDING THE USE OF DO NOT RESUSCITATE (DNR) ORDERS IN DEPARTMENT INSTITUTIONS › Section 191-3-III - ADVISABILITY OF CPR IN LIGHT OF THE MEDICAL CONDITION OF PATIENT

Current through 2024-29, July 17, 2024
A. Medical Condition
CPR, as a standing order, is based an the presumption of
				  potential medical benefit to the patient, outweighing the potential for causing
				  physical and mental injury. The presumption of benefit to the patient no longer
				  applies when the physician determines and documents that the application of CPR
				  is not justified because the patient is either in a terminal condition or
				  because CPR is medically contraindicated.
COMMENT
The prognosis of terminality may arise when an underlying
				  condition, such as end stage cancer, or end stage Alzheimer's disease is
				  considered to be medically incurable or untreatable in terms of currently
				  available technology and where death as a result of the natural history of the
				  disease process or medical problem will likely occur within one year. CPR may
				  be medically contraindicated when resuscitation is likely to not only be
				  ineffective in restoring normal functioning but might also induce a state of
				  prolonged pain and suffering.
D. Discussion with Others
Because of its grave nature and consequences, a DNR decision
				  should be made under conditions that permit consultation and reasoned decision
				  making by all parties involved. Prior to and after the entry of a DNR order, it
				  is the responsibility of the attending physician to ensure that the order and
				  its meaning are discussed with appropriate members of the hospital staff,
				  especially the nursing staff, so that all involved professionals understand the
				  order and its implications. Each institution shall develop a procedure to
				  resolve staff disagreement concerning the entry of a DNR order for a particular
				  patient.
When a physician believes that a patient is either in a
				  terminal condition or that the patient's condition Is such that CPR is
				  medically contraindicated, he shall request a separate evaluation of the
				  patient's medical condition from another physician. If the second evaluation
				  confirms the first, the physician shall then attempt to discuss the issue of
				  CPR with the patient to determine the patient's wishes.
C. Prior Consent
A physician shall obtain authorization from an appropriate
				  party or from an advance directive of the patient prior to the entry of a DNR
				  order.
(1) Decision making by patient
				with capacity
A patient who is determined by his attending physician to
				  have the capacity to make a decision with respect to resuscitation and who is
				  in a terminal condition or whose condition is such that CPR is medically
				  contraindicated, shall be fully informed of the risks, benefits and
				  alternatives of a DNR order by his attending physician. The consent of such
				  patient shall be obtained in writing prior to the entry of a DNR order in the
				  record by the attending physician.
If a patient with a guardian is determined to have the
				  capacity to make a decision with respect to CPR, the guardian shall be notified
				  and his consent also obtained prior to the entry of a DNR order in the medical
				  record. If such a patient expresses a wish to be resuscitated, his wishes are
				  controlling.
If the patient has no objection, family members who are
				  reasonably available should be informed of a DNR order by the attending
				  physician or a staff member acting on his behalf and every effort shall be made
				  to involve such members. However, the wishes of the patient are controlling. If
				  the patient does not wish family members contacted the patient's privacy shall
				  be respected and the patient's wishes shall be documented in the record.
If a patient with capacity later becomes incapacitated, an
				  advance directive (prior written consent, a living will or a durable power of
				  attorney) of the patient with respect to CPR shall be honored by the attending
				  physician.
(2) Decision
				making for Incapacitated Patient
If the attending physician has attempted to discuss the issue
				  of resuscitation with the patient and has concluded that the patient is
				  incapacitated, he shall obtain a second opinion on the issue of capacity from a
				  physician or licensed clinical psychologist who is not involved in the
				  treatment of the patient. If the second opinion fails to find incapacity, the
				  procedure outlined in Section III(C)(1) above shall be followed. If the second
				  opinion affirms the physician's finding of incapacity, the attending physician
				  shall discuss the issue of resuscitation with an appropriate surrogate.
(a) Surrogates
One person from the following, to be chosen by the attending
				  physician or designee in order of priority stated, when a person in the prior
				  class is not reasonably available, willing or competent to act, shall have the
				  authority to act as surrogate for decision making on behalf of an incapacitated
				  patient:
an agent appointed by the patient under it durable power of
				  attorney for health care decision making;
a legal guardian or legally responsible parent of the
				  patient.
COMMENT
Power of Attorney
A properly executed durable power of attorney may be used in
				  Maine to make health care decisions on behalf of an Incapacitated person. A
				  document purporting to grant this type of authority to another must 1)
				  specifically state that the power outlasts the disability of the principal (the
				  person on whose behalf the agent acts), 2) specifically grant to the agent the
				  power to sake health care decisions and 3) must be notarized. The agent
				  continues to have this authority even if a guardian is subsequently appointed.
				  (A court would have to formally terminate this type of power of
				  attorney.)
Guardian
The extent of the guardian's power should be carefully
				  determined. Some guardians have limited power over the ward's personal affairs.
				  Note also that a conservator does not have the power to make personal health
				  care decisions on behalf of his/her ward.
Minors
An emancipated minor is legally competent to make medical
				  treatment decisions. An unemancipated minor is legally incompetent to make most
				  treatment decisions -- that right rests with his legal guardians) which in most
				  cases is his parent(s). Nevertheless, the attending physician should in every
				  case attempt to discuss the issue of CPR with a minor patient as well as with
				  his guardian. If a minor patient is unable to understand or communicate his/her
				  wishes, his guardian may make the decision as the appropriate surrogate.
				  However, if a minor patient is able to express an opinion with respect to this
				  decision, his wishes shall be given great weight. If a minor patient wishes not
				  to be resuscitated, the legal guardian of the minor must also consent prior to
				  the entry of a DNR order. If the minor patient expresses a desire to be
				  resuscitated but the legal guardian consents to a DNR order, no DNR order may
				  be written without court order.
(b) Standard for surrogate decisions
The attending physician shall inform the surrogate of the
				  patient's diagnosis, prognosis, the risks, benefits and alternatives to CPR and
				  shall provide any other information necessary so that the surrogate can make an
				  informed decision regarding the use of resuscitation for the patient. The
				  surrogate's decision regarding CPR should be based on an understanding of the
				  patient's previous or current known wishes or, if the patient's wishes are
				  unknown and cannot be ascertained, on the basis of the patient's best
				  interests. The physician shall inform the surrogate of any explicit verbal or
				  written directives of the patient on the issue known to the physician. The
				  surrogate should make a good faith effort to involve all concerned family
				  members In a CPR decision. The physician shall obtain the written informed
				  consent of the surrogate prior to the entry of a DNR order in the patient's
				  medical record. In an emergency, when the surrogate is unable to be physically
				  present, verbal consent immediately followed by consent in writing shall serve
				  as authorization for a DNR order. -