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No Code and Do Not Attempt Resuscitation Orders

The North Carolina Medical Society supports the provision of services to dying patients in the most sensitive and humane manner under the circumstances. North Carolina’s Right to a Natural Death Act recognizes a patient’s right to a peaceful and natural death. It outlines an optional and nonexclusive procedure for respecting this right that provides a safe harbor of protection from liability in circumstances involving withholding or withdrawing life-prolonging measures including artificial nutrition or hydration from a patient who: is unable to make and communicate decisions and who has an incurable or irreversible condition that will result in the declarant’s death within a relatively short period of time; or becomes unconscious and, to a high degree of medical certainty, will never regain consciousness; or suffers from advanced dementia or any other condition resulting in the substantial loss of cognitive ability and that loss, to a high degree of medical certainty, is not reversible. The statute defines “life-prolonging measures” as “medical procedures or interventions that in the judgment of the attending physician would serve only to postpone artificially the moment of death by sustaining, restoring, or supplanting a vital function, including mechanical ventilation, dialysis, antibiotics, artificial nutrition and hydration, and similar forms of treatment. Life-prolonging measures do not include care necessary to provide comfort or to alleviate pain.” It encompasses CPR in circumstances where the physician has determined that this intervention would serve only to postpone artificially the moment of death.

While these procedures are useful and recommended as a liability management device under appropriate circumstances, the Act also authorizes following the common law, and so doing may allow greater sensitivity to patient needs. The common law continues to grow through court decisions and addresses questions relative to the patient’s right to control his or her medical care decisions and to die with dignity. While the statutory procedures are available, the physician has a degree of freedom in this area to use the often less stringent common law sensitively to mesh patient needs and rights with legal constraints. In addition to recognizing a Declaration for a Natural Death, North Carolina law further provides for a Health Care Power of Attorney, Portable Do Not Resuscitate Orders and a Medical Orders for Scope of Treatment. Immunity protects persons and institutions that honor these documents in good faith.

The presence of a do not resuscitate (DNR) order or an order to limit, withhold or discontinue life-prolonging measures does not relieve the physician of responsibility to continue monitoring the condition of the patient, to provide all necessary symptomatic relief, and to write other orders consistent with the plan of care.

Should a conflict arise between and among the medical staff, the nursing staff and/or the patient’s family regarding the issuance of a DNR order to limit, withhold or discontinue life-prolonging measures, the institution’s ethics committee or other similar mechanism should be consulted to provide a forum for resolving the conflict.

General guidelines applicable to all “No Code Blue” or DNR orders:

  1. Orders shall be entered only on the authority of the patient’s physician. A second physician’s opinion or signature is not required.
  2. The orders shall be in writing and placed in the physician’s order section of the medical record.
  3. The physician shall state in a progress note of the patient’s medical record the basis for entering the DNR order. The entry should include the patient’s medical status and prognosis and should indicate that the order is in keeping with the patient’s rights, known wishes or values and best interest.
  4. Further supporting documentation also may summarize conversations with family members or the patient’s representative(s). In the event the patient has an advance directive, a copy should be included in the patient’s record.
  5. The acceptability of telephone or oral DNR orders shall be established in individual health care institutions or agencies by policies jointly developed by the medical staff and the administration.
  6. Orders to limit, withhold or discontinue life-prolonging measures, including a DNR order, shall be regularly reviewed and renewed in writing in a timely manner under policies established by the medical staff and the administration of the institution or agency.
  7. DNR orders shall also be reviewed whenever there is: (a) a change in the patient’s condition or prognosis, including decisional capacity; (b) a change in the patient’s, family’s or surrogate’s wishes; (c) a change in the patient’s physician; or (d) a transfer to another care setting.


(Board Report-2019, Issue 3, adopted 07/27/2019)