Regulations Related to Providing Certain Health Care Services

     Re: Advance Directives and DNAR Orders

Thank you to Mary Pat Rapp, Ph.D., GNP, for her guidance in answering this question.

Q:  I am a FNP working with five physicians rounding on over 500 of their long term care patients residing in various nursing facilities. The physicians and facilities would prefer I provide the second signature on papers verifying a patient’s and families’ wishes regarding resuscitation and treatment at end of life. I have not found anything in writing that specifies if NPs are permitted to write DNAR orders. Could you help me find any laws or rules that apply?
           
A:  The federal regulations are silent about whether or not NPs, or any APN, can sign paper work and orders for “Do not attempt resuscitation” (DNAR). While it is certainly in the scope of practice for NPs to sign DNAR orders, unfortunately Texas law, §§166.033 – 166.034 specifies physicians must note the patient’s wish to not be resuscitated. Consequently, until the law is changed, CNAP recommends that NPs do not sign DNAR orders or the “Out of Hospital DNAR” form unless you are signing as a witness and meet the requirements under §166.003, Texas Health& Safety Code (see below).

Section166.034, Texas Health & Safety Code, entitled ”ISSUANCE OF NONWRITTEN DIRECTIVE BY COMPETENT ADULT QUALIFIED PATIENT” specifies the physician must be a witness to the patient’s statement if the advance directive is not written. It states:

(a)   A competent qualified patient who is an adult may issue a directive by a nonwritten means of communication.
(b)  A declarant must issue the nonwritten directive in the presence of the attending physician and two witnesses who qualify under Section 166.003, at least one of whom must be a witness who qualifies under Section 166.003(2).
(c)  The physician shall make the fact of the existence of the directive a part of the declarant's medical record, and the names of the witnesses shall be entered in the medical record.

The witnesses specified in §166.034 are described in §166.003, Health & Safety Code.

§ 166.003.  WITNESSES.  In any circumstance in which this chapter requires
the execution of an advance directive or the issuance of a nonwritten advance
directive to be witness

(1)  each witness must be a competent adult; and
        (2)  at least one of the witnesses must be a person who is not:

(A)  a person designated by the declarant to make a treatment decision;              
(B)  a person related to the declarant by blood or marriage;              
(C)  a person entitled to any part of the declarant's estate after the declarant's death under a will or codicil executed by the declarant or by operation of law;         
(D)  the attending physician;
(E)  an employee of the attending physician;     
(F)  an employee of a health care facility in which the declarant is a patient if the employee is providing direct patient care to the declarant or is an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility;  or
(G)  a person who, at the time the written advance directive is executed or, if the directive is a nonwritten directive issued under this chapter, at the time the nonwritten directive is issued, has a claim against any part of the declarant's estate after the declarant's death.

While NPs may not write the DNAR order, they may: 1) write verbal orders at the direction of an attending physician who witnessed the declarant’s statement; 2) write “do not hospitalize, do not use artificial nutrition hydration;” 3) sign forms in which the family/resident chooses the level of care since these are care plans, not orders; and 4) witness living wills. Of course, NPs should discuss advance directives with residents and families and document the discussion and decisions in progress notes and on any appropriate forms in accordance with the guidelines below.

Whether a DNAR order is obtained in a hospital or nursing facility, NPs can complete the required documentation related to the DNAR order if the NP discusses the patient’s wishes with the patient and family or legal guardian. The state of Texas says that DNAR orders need to be accompanied by the following documentation: 1) persons with whom the NP spoke, and if not the resident/patient, why not, and the relationship to the resident; 2) summary of the discussion and 3) decision reached.

Another very important form referenced in your question is the “Advance Directive.” This document, also known as a living will, is the document through which an individual conveys their wishes for treatment should they have a terminal condition and cannot speak for themselves. The NP can sign as a witness to this document if they are not employed by the attending physician or the hospital or nursing facility. This is also the document that all of us should download, complete, and sign to make our wishes known to our own family members should we be unable to speak for ourselves.