This section includes guidelines for Life sustaining therapies and Do Not Resuscitate Orders (DNR) or Removal of Life Support for Children in the legal custody of the Division. This decision will be made in consultation with the child (if mentally and physically capable of making the decision), biological parent, guardian, guardian ad litem, juvenile court, the child’s physician, the child’s Children’s Service Worker, care provider, and at least two physicians who have access to the child and the child’s records.  The final decision regarding the use of life support and DNR orders or removal of life support for children in the legal custody of the Division shall rest with the court or the family if the court agrees.  Children’s Division and the Department of Social Services will not take a partisan position on Life Support/Sustaining Therapies in those cases in which the doctors are recommending a DNR or removal of life support.  We will provide unbiased, objective facts to the court, but we will not make any recommendations as to the final outcome.  The Department’s position in these situations is that the decision must be made by the court after reasonable notice and an opportunity for a hearing is given to the child’s parents, the Guardian ad litem (GAL), the Juvenile Officer (JO) and any other interested parties to provide input into the case as appropriate.  The department will not take the position that the responsibility for making DNR or Removal of Life Support decisions should be vested in a foster parent or (former foster parent) or other third party unless ordered by the court.

The wishes of a child with a life threatening illness may be taken into consideration when making major decisions regarding medical care for the child, especially a DNR decision as to what weight to give to the child’s wishes is a judgment that must be based on the individual facts of each case considering factors such as the ability of the child to understand his/her condition, to make decisions; the maturity of the child, the wishes of the parents and other parties.

NOTE:  Life sustaining therapies are defined as tube feeding, respirator, physical therapies to sustain life, intravenous fluids (IV), etc.

When circuit office staff is confronted with situations which require the continued use of life support systems or the removal of life sustaining therapies and those cases in which the doctors are recommending a DNR or removal of life support for children within the care and custody of the Children’s Division, staff shall:

• Immediately gather appropriate identifying and medical information including:
  • Condition and prognosis of the child;
  • Other pertinent information regarding the child, i.e., age, birth date and location;
  • Parent(s) name and address; if there is no parent(s), then the nearest relative
  • Most recent court order; and
  • Other appropriate medical and identifying information.
• Notify immediately, via telephone, and provide an explanation of the child’s situation and appropriate information based on Step 1.
• Refer such situations to the office of the Children’s Division Director for review.
• CD shall not be the agency to file a motion with the court asking for the court to make a DNR or removal of Life Support decisions. The motion should be filed by the JO or the GAL or parent(s) whose parental rights have not been terminated. If the JO and/or GAL or parent(s) refuses to file such a motion, then Division of Legal Services may file a motion notifying the court that:
  • The child is seriously ill and the doctors are recommending DNR or removal of Life Supports. The best practice would include a written statement from the doctor attached to the motion;
  • CD does not make DNR or Removal of Life Support decisions and does not have a specific recommendation to make regarding the child; and
  • CD requests that the court take evidence on the child’s condition and enter an appropriate order.
• Notify the birth parent(s)/kinship of the hearing. Notice of hearing must be in writing. It is preferable to deliver the notice personally, but if this is not possible then it should be sent by certified mail so there is documentation to show the efforts to notify interested parties.  If CD does not know the location of a parent or guardian CD/Division of Legal Services needs to take all reasonable steps to locate that individual and provide them reasonable notice so that they have an opportunity to present information to the court.  The steps taken to locate, the absent parent or guardian needs to be documented in the file.
• Notify the juvenile office and/or juvenile court immediately if the medical facility does not provide all appropriate information or there is a concern for the child’s health while a review is being conducted.
• Immediately submit a written report containing the information outlined above to the regional director.
• Before, during, and after the decision has been made to begin or discontinue life support systems, establish open communications with the birth parent(s), foster parent(s) and sibling(s) of the child.
• County office staff will update Regional Director, as necessary, on any changes in the child’s condition during the review process.
• Assist the family by providing or arranging contact with support groups, counseling or any other service necessary to aid the family in the event of the child’s death.

Related Practice Points and Memos:

7-9-19 – PP19 CM-01 – Timely Informed Consent – Inpatient Hospitalizations and Medication Management Checkups

7-26-19 – CD19-47 – Informed Consent for Psychotropic Medication (Form CD-275)

10-11-19 – DK19-04 – Immediate Implementation of Best Practices Regarding Behavioral Health Care and Medical Records

4-9-20 – PP20-CM-03 – Mandatory Psychotropic Medication Reviews

7-23-20 CD20-34 –Introduction to Child Welfare Manual policy updates to align with best practices and comply with Joint Settlement Agreement requirements.

Upon notification the Regional Director will:

• Call and advise the Children’s Division Director of this medical emergency, relaying the information concerning the child as provided in the required staff report.
• Forward immediately, upon receipt, a copy of the written report containing the information outlined above to the Children’s Division Director.