Most likely schools evoke our best memories as lively places with active playgrounds, determined classrooms, band performances and Friday night football games.
The common factor is happy, healthy and engaged children. As educators, we make and sustain these places. Our codes of ethics place students’ interests at the core of our professional service. We act “in loco parentis” – in the place of a parent.
But what happens when we receive a medical directive that requires that we do not resuscitate one of our students? Do we allow students whose parents have given a directive saying “Do Not Attempt Resuscitation” (DNAR) to die at school? How do we reconcile this ethical dilemma of serving the best interests of our students when they face impending death?
Medically fragile children
Do Not Attempt Resuscitation – DNAR – is a request to not attempt cardiopulmonary resuscitation (CPR) if a person’s heart or breathing stops. The American Academy of Pediatrics (AAP) believes that it is ethically acceptable to forego CPR for children and adolescents when it is unlikely to be successful or when the risks outweigh the benefits.
As medical and technological advances prolong life, they also present challenges. Children who earlier would have had short lives due to incurable medical conditions are not only able to live longer, but also attend school. Such medically fragile students – often with a terminal diagnosis – wish to live a “normal” and/or minimally encumbered life for as long as they can.
The National Association of School Nurses notes that the number of students with chronic health conditions is growing. There are some 14.2 million children of school age with chronic health conditions, including such conditions as end-stage heart, liver or kidney disease as well as cancer.
When attending school, such students could experience several sudden difficulties with functions such as breathing or swallowing, and repeated or chronic pain. Consequently, they may require health and related services beyond those generally required by children.
In 2014 over 16 percent of schools had at least one medically fragile student, receiving such medical services as urinary catheterization, medications given intravenously or support for breathing through breathing tubes.
Ethical dilemmas
Can a school refuse to follow an advanced directive to not resuscitate one of their medically fragile students in opposition to the expressed wishes of the child’s parents? Should the legitimate concerns of the school outweigh the legitimate and agonizing decision of the parents?
As an assistant principal, I (Todd) faced the emotional and professional challenge of accommodating a terminally ill sixth grade student. My coauthor (Winston) explores some of the ethical issues that educators have to deal with, when faced with such challenges.
The impending death of a student is unlike most challenges educators face. There are many dilemmas experienced by educators within schools when they receive a directive from a parent to not resuscitate their child.
Parents of other children may not want a child with a DNAR in the same class as their child, believing that it could be physically, socially or emotionally harmful to their child. I faced this with my sixth grade student who had terminal brain cancer. Some parents wanted to move their children out of the classroom and others wanted me to move the terminally ill child out of the classroom.
Faculty and staff too could object to being placed in a situation in which they could not act.
Schools also need to confront what action to take if a student goes into cardiac arrest, what to do with the students in the vicinity or in classroom and whom to call. Additionally, they are faced with considering questions of whether a student with a DNAR should be kept from participating in off-campus activities such field trips.
Increase in DNAR orders
There has been an increase in the DNARs received by schools. Studies show that DNAR orders in schools increased from 29.7 percent in 2000 to 46.2 percent in 2006.
This could be partly due to the fact that following the promulgation of laws for children with special needs, not only can children with complex chronic conditions attend school, but their needs must be adequately addressed.
For example, the Individuals with Disabilities Education Act of 1997 (IDEA) requires a zero rejection of students with a disability, including medically fragile students. Similarly, section 504 of the Rehabilitation Act of 1973 requires that schools not discriminate against individuals with disabilities.
Consequently, with more and more students with disabilities coming to schools, there has been a significant increase of students being designated as Other Health Impaired – a category of disability under special education law related to chronic or acute health problems that adversely affects a child’s educational performance. Between 2005 to 2014, the number of such impairment increased by 51 percent.
Teachers, ethics and DNAR
DNAR orders are difficult enough for medical professionals who practice at hospitals where immediate medical care is available and ethics boards provide direct supervision.
They are, however, particularly troublesome for educators, including school nurses.
Educators have an ethical duty to exercise their professional judgments in the best interests of their students. They also have a legal duty to act in their students’ interests by taking reasonable steps to reduce the likelihood of foreseeable harm. These twin duties present difficulties for educators who wish to act well relative to their students with DNAR orders.
Educators need to be clear about the limits of their professional judgments, and how they define student interest. They also need to recognize what might lead to more harm for the student. A failure to be appropriately careful in these judgments may result in educators extending their personal values in potentially offensive, oppressive or unethical ways.
Educators and parents may best be served by knowing what their state law requires in this area on how a DNAR will be implemented, and how they could provide emotional support and ethical guidance for students, faculty, staff and parents deeply affected by this order.
The issues are certainly troubling, with no easy answers. This literal life and death decision is full of heartbreak for all involved.