Current through Register Vol. 56, No. 18, September 16, 2024
(a) "Do Not Hospitalize" orders ("DNHs") are orders written by a physician or advanced practice nurse in collaboration with a physician, which must be made part of the resident's medical record in the same way as any other order.
(b) DNHs can be appropriately utilized in a facility, provided the following safeguards are employed:
1. Prior to writing a DNH, the attending physician or advanced practice nurse after consultation with the attending physician shall:
i. Discuss the circumstances surrounding his or her decision to enter such an order with the resident, or if the resident is incapacitated, with the resident's surrogate decision-maker or Health Care Proxy, as appropriate;
ii. If a resident has a court appointed guardian, consult with that guardian before the DNH order is written;
iii. If there is no surrogate decision maker, designated proxy, or guardian, the physician or advanced practice nurse shall exercise his or her best professional judgment regarding the order, and may seek consultation with the Ombudsperson or a regional long-term care ethics committee;
iv. Document the above-referenced discussions; and
v. Document the resident's medical history, diagnosis, prognosis as they relate to the DNH;
2. The DNH shall be clear and precise, and include appropriate plan of palliative care;
3. If the resident has the capacity to make health care decisions, and requests that the attending physician or advanced practice nurse place a DNH on his or her chart, the attending physician or advanced practice nurse in collaboration with the attending physician shall determine that the resident is fully informed, aware of his or her diagnosis and prognosis, the risks, benefits and any alternatives, that this is in fact the resident's wish, and that there is no coercion; and
4. If the resident has executed a DNH clause as part of an Advance Directive, that clause shall not be effective as a DNH order unless and until the attending physician or advanced practice nurse in collaboration with the attending physician has followed (b)1 through 3 above, and entered a DNH order in the resident's medical record.
(c) A resident, responsible family member, a health care proxy, or a surrogate decision-maker can initiate the request that the physician or advanced practice nurse write a DNH and enter it in the resident's medical record.
(d) The utilization of a DNH does not prohibit a facility from sending a resident to the hospital in appropriate instances, for example, for sutures in the case of a laceration, or for x-rays after a fall.
(e) The appropriateness of sending a resident with a DNH to the hospital shall be evaluated and determined by the physician or advanced practice nurse in light of the presenting problem and the resident's overall medical condition.
