New Harmonized Policies

Published:
September 15, 2026

What You Need To Know

Three new harmonized policies addressing Code Status and Airway Management Orders and Forgoing Life Sustaining Treatment will go into effect on October 12, 2026. These network wide policies are a result of a years-long effort with input from a multidisciplinary team of network and hospital leaders and care providers. 

The new policies harmonize practices across Hackensack Meridian Health, ensuring that the care we provide honors our patients’ goals and preferences, and is consistent with current legislation and best practices. 

What You Need to Know 

Why?

Code status and airway management orders tell the care team what to do in moments of crisis. Code status orders indicate whether a code should be initiated for a patient in cardiopulmonary arrest. Airway management orders indicate whether the patient should be intubated for respiratory distress. Though the default is to initiate a code when there is no DNAR order,  Code status and Airway Management orders communicate to the care team that a discussion tailored to the patient’s specific circumstances has been held with the patient (or surrogate for a patient who lacks capacity or the parent/guardian for a minor).

Other decisions to forgo life-sustaining treatment are made according to the same standards as decisions about Code Status and Airway management orders. An adult patient who has decision making capacity has the right to refuse medical interventions, including life sustaining medical treatment. 

The policies detail standards for decisions made by a surrogate on behalf of a patient who lacks capacity, a parent/guardian on behalf of a minor, and for patients who lack capacity and have no one to make decisions on their behalf. 

The policies also address documentation, implementation,  and review of Code Status and Airway Management orders, as well as resolving relevant conflicts.

These policies bring one consistent approach to all HMH settings so that every team member knows what these orders mean, how they are implemented, who can make decisions, and who to turn to when conflict arises. 

What?

Three new harmonized policies addressing Advance Directives policy will go into effect on October 12, 2026. 

The harmonized policy on Code Status and Airway Management Orders addresses definitions, decision making, documentation, implementation, and review of Code Status orders (Do Not Attempt Resuscitation (DNAR), DNAR with comfort focused measures, and Full Code) and Airway Management orders (Do Not Intubate (DNI) and Intubate). 

Key points of this comprehensive policy are:

  • Foundational Principles: The policy honors patient autonomy and appropriate surrogate decision-making. 
  • Important definitions:
    • DNAR (Do Not Attempt Resuscitation): This is a medical order to forgo CPR (BLS/ACLS) only in the event of cardiopulmonary arrest (i.e., no pulse and/or no breathing). It is not an advance directive and does not preclude other medical treatments. 
    • DNAR with Comfort Focused Measures: In addition to forgoing resuscitation, other life-sustaining treatments will not be escalated, and the primary focus of care is comfort. The patient’s comfort focused treatment plan is documented in a progress note in the patient’s medical record.
    • DNI (Do Not Intubate): This is an airway management order to forgo intubation and ventilator support for respiratory distress. It does not automatically mean "do not resuscitate." Patients with DNI orders can still receive other treatments like supplemental oxygen, medications for comfort, and manual airway assistance. 
  • Default action: in the absence of a DNAR order, a code is initiated in accordance with this policy. Duration of CPR is a clinical decision made by the clinical team during CPR, based on their clinical assessment and evaluation of the patient. 
  • Discussion and documentation: discussion is tailored to the patient’s specific clinical circumstances, includes key elements, and is documented in the medical record.  
  • APPs: APNs and PAs may write code status and airway management orders subject to individual hospital rules and regulations. Changes in code status are discussed with the Attending Physician within 24 hours of the change.
  • Residents: Residents must discuss code status and airway management orders with the patient’s attending physician. Code status and airway management orders written by residents in PGY1 require co-signature by an attending physician within 24 hours. 
  • Limitations: Decisions about code status and airway management orders made by a surrogate on behalf of an adult patient who lacks capacity or by the parents or legal guardian on behalf of a minor are limited to the clinical circumstances detailed in this policy.
  • Patients who lack capacity and have no surrogate: a special medical guardian is appointed to make decisions about DNAR and DNI orders. Bioethics consultation is required for decisions to forgo life-sustaining treatment for an incapacitated patient who has no surrogate, unless the sole decision is about a DNAR order. 
  • Contemporaneous wish: a  patient's clearly expressed current wish for medically appropriate life-sustaining treatment overrides any contrary decision by a surrogate and any contrary statement in their own advance directive, even when the patient lacks capacity. Bioethics is a resource when the patient’s contemporaneously stated wish conflicts with their advance directive, prior statements, or preferences of the surrogate decision maker.
  • Minors: Unless one parent has been legally granted sole decision making authority for the minor patient, prior to the writing of a DNAR and/or DNI order for a minor, consent from both parents, or the legal guardian, is required. 
  • MSNJ Out of Hospital DNR Form: generally honored in the Emergency Department. In inpatient, ambulatory procedure, and post acute settings it is honored until the patient is evaluated by a practitioner and appropriate orders are entered into the medical record. 
  • POLST Form: corresponding orders are entered into the patient's medical record in accordance with the HMH POLST Policy.
  • Review of code status and airway management orders: required by the practitioner at key points of transition. 
  • Conflicting orders: When DNI + Full Code is chosen, the practitioner makes diligent efforts to clarify these potentially conflicting orders. 
  • Operative and non-operative procedures: DNAR and DNI orders are not automatically suspended. See also the HMH policy Informed Consent Policy for Surgery or Non-Operative/Invasive Procedures, Anesthesia Services, Sedation, and Blood Transfusions (including Minors). 
  • Outside the Hospital: Inpatient DNAR and DNI orders expire at the time of discharge. They are not honored by EMS or other facilities. A POLST, which covers code status, airway management and other interventions, is an active medical order honored  in all settings. The MSNJ Out of Hospital DNR form (for DNAR only) is also honored outside the hospital. 
  • Honoring the patient’s decision: If a patient consented to a DNAR and then lost capacity, the order is honored unless particular circumstances apply. 
  • Conflict Escalation Pathway: If a disagreement about code status cannot be resolved through discussion with those involved, notify Risk Management. Bioethics is an additional resource.
  • Conflict Favoring "Full Code": In a disagreement where the patient or surrogate requests "Full Code" against the practitioner's judgment, the patient's status remains "Full Code" until the conflict is formally resolved.

The harmonized policy on decisions to forgo life sustaining medical treatment addresses such decisions other than DNAR and DNI orders and delineates the standards for decision making.

The policy on Decision Making about Forgoing Life Sustaining Treatment, including Code Status and Airway Management Orders for Patients for whom Bureau of Guardianship Services is Providing Guardianship Services ensures adherence to relevant regulatory standards for decisions on behalf of developmentally delayed adults for whom BGS provides guardianship.

When?
The new network wide policy will go into effect on October 12, 2026. Impacted physicians and team members have received notice of an assigned learning module.

Questions?
See FAQs here https://myhmh.hmhn.org/en/departments/bioethics/bioethics-policies 
More information about the HMH Bioethics Institute can be found here https://myhmh.hmhn.org/en/departments/bioethics 
Email CodeStatusPolicy@hmhn.org  

Click here to view a flyer about the new policy. Please help us spread the word by sharing with your colleagues and teams.