A Valid DNR, Two Parents, and a Plugged Tracheostomy

Read the document itself. Determine what it actually prohibits - typically compressions and sometimes intubation - and what it plainly does not: oxygen, suctioning, tracheostomy care, bronchodilators, antibiotics, fluids, and transport.

A DNR is not a do-not-treat order. A mucus plug in a tracheostomy-dependent child with a patent airway is a reversible problem. Suctioning, saline instillation, exchanging a plugged trach, and escalating the ventilator are routine care, not resuscitation, and are consistent with the mother's stated goals unless she says otherwise. The question to ask her is not 'do you want treatment' but 'what are you hoping for from this episode - comfort here, or transfer for escalation?'

Practical decisions in the next 30 minutes:

• Optimize the airway and oxygenation now - that is what everyone wants.
• Clarify the goal of transfer with the mother. If comfort-focused, transfer may still be appropriate to a team that knows this child, or may not be.
• Confirm the receiving hospital accepts the patient and knows the code status and goals.
• Ask the receiving palliative care team to be involved, now, before arrival - this conversation will not be resolved in the ED during a decompensation.
• Document verbatim what each parent said and when.

A surrogate can revoke a DNR at any time, and does not need anyone's agreement to do so. The most recently expressed directive generally governs.

That means the operative order is now full resuscitation, and the team should not continue to operate under the DNR while the parents disagree. This is uncomfortable but not ambiguous.

Steps:

• Document both statements verbatim, with times, in the transport record.
• Notify the ED attending, the receiving hospital, and your medical director.
• Ask the receiving hospital's palliative care and ethics resources to begin the conversation now, before arrival.
• Continue resuscitation-oriented care in the meantime - which, conveniently, overlaps almost entirely with the airway care you were already doing.
• Do not ask the parents to resolve their disagreement in the ED while their child is decompensating, and do not take sides.
• Address the mother's concern about suffering directly with adequate analgesia and sedation; 'do everything' and 'do not let him suffer' are not opposites, and saying so out loud often reduces the conflict.

For the order to function:

• The original, valid document must physically travel with the patient. A scanned copy in a chart you leave behind is not useful at 60 mph.
• It must be valid in the transport setting - scope of out-of-hospital DNR orders varies by state and may or may not cover a transport team. Confirm this before departure rather than discovering it during an arrest.
• The whole crew must be briefed on the plan, the code status, the goals of care, and each person's role.

If the order is missing, ambiguous, or revoked, the default is to resuscitate.

If he arrests with the father's revocation in effect:

1. Direct the driver to stop the vehicle. CPR in a moving vehicle is ineffective and unsafe.
2. Begin compressions and bag-mask ventilation, and consider reversible causes - mucus plug, tube obstruction, pneumothorax, hypoxia.
3. Contact online medical control and the receiving hospital.
4. Assign one team member to support the mother; do not let the crew litigate the ethics question in the back of the rig.
5. Continue resuscitation unless a valid, applicable order is produced or medical direction directs termination.

When he arrives, hand off the timeline of both parents' statements clearly - the receiving team will need to continue a conversation that has only just begun.