A Resident who is incapable of making an informed decision may be treated without consent if

1. The treatment is of an emergency medical nature; AND
2. A legally authorized decision maker is not available; AND
3. The Attending Physician determines:
1. That there is a substantial risk of death or immediate and serious harm to the Resident; and
2. Within a reasonable degree of medical certainty, the life or health of the Resident would be adversely affected by delaying the treatment to obtain consent.

1. Medically Ineffective Treatment.

Physicians are not required to prescribe or render Medically Ineffective Treatment. Therefore:

1. A Resident's Attending Physician may withhold or withdraw as Medically Ineffective, a treatment that, under generally accepted medical practices, is life-sustaining in nature only if:
1. The Resident's Attending Physician and a second physician certify in writing that the treatment is Medically Ineffective; and
2. The Attending Physician informs the Resident or the Resident's Agent or surrogate about the decision.
2. If the Resident is being treated in the emergency department and only one (1) physician is available, the certification of the second physician is not required.
2. Ethically Inappropriate Treatment

Physicians are not required to prescribe or render treatment which the physician determines to be ethically inappropriate. If the physician makes such a determination, the physician must inform the Resident, the Resident's Agent and/or the surrogate decision maker. In addition, the physician should comply with the procedures set forth in Section V.

3. Do Not Resuscitate Orders

Consent is not required for the entry of a Do Not Resuscitate order if the order is entered based on the physician's judgment that resuscitation would be medically ineffective, see procedures under Section III.B.1. However, when the Resident has a guardian of the person, special procedures are to be followed.

1. The guardian must be notified of the DNR order and should be provided a copy of the certification/s and the DNR order; and
2. The guardian will be instructed to notify the court of the physician's decision regarding withholding CPR due to its medical ineffectiveness, and should forward a copy of the certification/s and DNR order.
According to the Maryland Attorney General, a Circuit Court's order governing the guardian's right to consent does not affect the attending physician's right to refuse to authorize CPR if it would be medically ineffective (a finding that is confirmed by a second physician), permitting the physician to place a DNR order on the chart without the guardian's consent. The opinion discussing this matter is available here: www.marylandadvancedirectives.com/pdf/79oag218.pdf.

An advice letter further elaborating on the guardian's responsibility under these circumstances is available here: www.marylandadvancedirectives.com/pdf/advice-tarzian-011703