Medical Records and the Law

288 CHAPTER 8: DOCUMENTATION AND DISCLOSURE:SPECIAL AREAS OF CONCERNthe CPR team by announcing “Code Blue,” so the order might read“No Code Blue.” DNR orders provide an exception to the universalstanding order to provide CPR. For prehospital and emergency departmentcare, consent for CPR is implied unless a valid, written advancedirective states otherwise. With respect to emergency care, thepresumption at law is that the patient would choose to be resuscitatedwere he or she able to express such an opinion. Moreover, the AmericanMedical Association (AMA) Council on Ethical and Judicial Affairshas stated that “[e]fforts should be made to resuscitate patientswho suffer cardiac or respiratory arrest except when circumstances indicatethat administration of cardiopulmonary resuscitation (CPR)would be inappropriate or not in accord with the desires or best interestof the patient.” 68Joint Commission standards require that healthcare organizationsestablish policies and procedures regarding the decision to withhold resuscitativeservices. 69 Moreover, state statutes in this area typically requirethat the physician who is primarily responsible for the patient’scare is the only person who may write DNR orders and inscribe themin the patient’s medical record. 70 An appropriate consent form or refusalof treatment form should also be signed by the patient, the patient’sfamily, or the patient’s surrogate or proxy; a physician mustobtain the informed consent of a competent patient or of an incompetentpatient’s family or other representative before entering a DNRorder.Typically, hospital policies require daily review of DNR orders todetermine if they remain consistent with the patient’s condition andthe desires of the patient or patient’s representative.If a patient is incompetent, a healthcare provider should proceedwith caution before placing a DNR order in the medical record or failingto respond in the event of cardiopulmonary arrest, unless a writtenadvance directive such as a living will clearly indicates the patient’schoice. In one leading case, a court ruled against a physician who, afterconcluding that a patient was incompetent, issued a no-code order in68American Medical Association, Code of Medical Ethics, E-2.22.69Joint Commission, 2005 Accreditation Manual for Hospitals, Standards RI.2.80, PC.9.30;Joint Commission, 2003–2004 Accreditation Manual for Health Care Networks, StandardRI.3.2.70See, e.g., Alaska Stat. § 18.12.010(b); Ga. Code Ann. § 31-39-4; Md. Code Ann.,Health-Gen., § 5-.602(f )(2).