10.28 End of Life Decisions for Children in Foster Care | CWS

Georgia Division of Family and Children Services
Child Welfare Policy Manual

Chapter:

(10) Foster Care

Policy Title:

End of Life Decisions for Children in Foster Care

Policy Number:

10.28

Previous Policy Number(s):

N/A

Effective Date:

November 2022

Manual Transmittal:

2022-03

Codes/References

O.C.G.A. § 31-1-14 Physician Orders Life-Sustaining Treatment (POLST) Forms
O.C.G.A. § 31-39-2 Definitions
O.C.G.A. § 31-39-4 Persons Authorized to Issue Order to Not Resuscitate
O.C.G.A. §§ 44-5-140 through 44-5-147 Georgia Revised Uniform Anatomical Gift Act

Requirements

The Division of Family and Children Services (DFCS) will:

Adhere to the laws governing life sustaining procedures, do not resuscitate and organ donation:
1. Life Sustaining Procedures (LSP) means medications, machines, or other medical procedures or interventions (e.g., cardiopulmonary resuscitation (CPR), respiratory and circulatory support, artificially administered nutrition, hydration), which when applied to a patient in a terminal condition or in a state of permanent unconsciousness, could in reasonable medical judgment keep the patient alive but cannot cure the patient; and where, in the judgment of the attending physician and a second physician, death will occur without such procedures or interventions.
2. Do Not Resuscitate (DNR) means an order not to attempt CPR in the event a patient suffers cardiac or respiratory arrest, or both.
  
  CPR means only those measures used to restore or support cardiac or respiratory function in the event of a cardiac or respiratory arrest.
3. Organ Donation (Anatomical Gift) means a donation of all or part of a human body to take effect after the donor’s death for the purpose of transplantation, therapy, research, or education.
Immediately notify the Division Director or General Counsel when:
1. A physician or hospital determines a child in the temporary or permanent custody of DFCS is at imminent risk of death or has a chronic illness that will result in the child’s death in the near future, and the physician recommends forgoing or discontinuing LSP.
2. A physician determines a child in the temporary or permanent custody of DFCS is at imminent risk of death or has a chronic illness that will result in the child’s death in the near future, and the treating physician requests an order of DNR.
3. A hospital representative or organ procurement organization requests an organ donation by a child in the temporary or permanent custody of DFCS who has reached the end of their life.
Notification to the Division Director or General Counsel shall be made through the chain of command (see Procedures).
Obtain direction from the Division Director or General Counsel on all requests for forgoing or discontinuing LSP, DNR and organ donation for children in the permanent custody of DFCS.
Defer decision making for children in the temporary custody of the DFCS to their parents, who retain the right to make end of life decisions.
Gather and provide to the Division Director or General Counsel, the child’s demographic information, information from the hospital to include but not limited to the child’s medical condition, prognosis, diagnosis, recommendations, and hospital/physician contact information. Share any new information on the child’s condition or other information from the hospital as it becomes available.
Maintain ongoing communication with the parents, hospital representatives and Division Director or General Counsel and other DFCS leadership.
Adhere to confidentiality and Health Insurance Portability and Accountability Act (HIPAA) provisions to prevent unauthorized disclosure of child abuse records and protected health information (see policies 2.5 Information Management: Health Insurance Portability and Accountability Act (HIPAA) and 2.6 Information Management: Confidentiality/Safeguarding Information).
Complete a child death, near fatality, serious injury (CD/NF/SI) report when applicable, and in accordance with policy 6.10 Special Investigations: Reporting a Child Death, Serious Injury, Near Fatality.

Procedures

Social Services Case Manager

Immediately notify the Social Services Supervisor (SSS) and County Director upon request or notice of the following for a child in foster care:
1. Forgoing or discontinuing LSP; or
2. DNR; or
3. Organ donation.
The County Director is responsible for notification to the Division Director or General Counsel and other DFCS Leadership (see County Director procedures below)
Gather the following information from the hospital:
1. Contact information for child’s primary care physician (name, hospital, phone number, fax number and email address);
2. Contact information for child’s attending/treating physician, if different (name, hospital, phone number, fax number and email address);
3. Contact information for the hospital social worker (name, address, phone number, fax number and email address);
4. Contact information for the organ procurement organization or hospital representative for organ donation if request is for organ donation;
5. Child’s diagnosis, prognosis and current medical condition. In addition:
  1. For LSP or DNR, a physician’s signed recommendation to forgo or discontinuing LSP or request for DNR, the medical care plan, and the physician’s rationale for the recommendation.
  2. For organ donation, a copy of the request for donation of the child’s organs and any accompanying official signed documents available.
Immediately escalate all questions from the hospital or procurement organization to the SSS and County Director.
If the hospital requests assistance in locating the child’s parents, make efforts to locate the parents in accordance with policy 19.21 Case Management: Unable to Locate. Provide the parents contact information to the hospital.
Provide support to the parents, including referral for services as needed (see policy 19.17 Case Management: Service Provision).

Do not share personal opinions or give recommendations regarding the decision the parents must make.
Participate in staffings to provide information and obtain guidance and direction.
Document all case management activities in Georgia SHINES within 72 hours of occurrence, including uploading supporting documents in External Documentation.

County Director

Immediately notify the Division Director or General Counsel and other DFCS leadership in their chain of command upon request or notice for forgoing or discontinuing LSP, DNR or organ donation.

Notify the boarding County Director if the child is placed in another county.
Include the following information in the notification or as it becomes available:
1. Child’s full name
2. Date of birth
3. Georgia SHINES Case ID
4. Whether the child is in permanent or temporary custody of DFCS
5. Placement information
6. Date child entered the custody of DFCS
7. Whether the child is subject to the Indian Child Welfare Act
8. Names and phone numbers of the County Director, SSS and SSCM
9. Contact information for child’s primary care physician (name, hospital, phone number, fax number and email address);
10. Contact information for child’s attending/treating physician, if different (name, hospital, phone number, fax number and email address);
11. Contact information for the hospital social worker (name, address, phone number, fax number and email address);
12. Contact information for the organ procurement organization or hospital representative for organ donation if request is for organ donation;
13. Child’s diagnosis, prognosis and current medical condition. In addition:
  
  For LSP or DNR, a physician’s signed recommendation to forgo or discontinuing LSP or request for DNR, the medical care plan, and the physician’s rationale for the recommendation.
  
  For organ donation, a copy of the request for donation of the child’s organs and any accompanying official signed documents available.
Do not delay providing notification to the Division Director or General Counsel due to missing information.
Participate in staffings to provide information and obtain guidance and direction.
Maintain ongoing communication with the Division Director, General Counsel and other DFCS leadership. Share all new information related to the child’s condition or other information provided by the hospital.
Maintain ongoing communication with the hospital representatives.

Social Services Supervisor

Ensure the County Director is notified upon receipt of a request for LSP, DNR or organ donation.
Assist the SSCM in obtaining demographic and medical information from the hospital or procurement organization.
Provide support and assist the SSCM in processing their emotions related to the child’s imminent death.
Remind the SSCM that they may seek further emotional support free of charge through the State of Georgia Employee Assistance Program.
Participate in required staffings to provide information to the Division Director or General Counsel.
Maintain ongoing communication with the County Director regarding any new information about the child’s condition or other information provided by the hospital.

Practice Guidance

How DFCS May Receive Requests

A request pertaining to LSP or DNR should begin with a written recommendation to DFCS by a treating physician that outlines the specific medical interventions that they believe should be withheld or withdrawn and the medical rationale. Initially, DFCS may receive a verbal notice, however a formal written request should be provided from the requestor.

Removal of Life Support

The removal of all medical procedures or interventions that serve only to prolong the process of dying or maintain the individual in a condition of persistent unconsciousness. This does not include the administration of medication or performance of medical treatments deemed necessary to alleviate pain or provide for the normal consumption of food and water.

Forms and Tools

N/A