45172. End-of-Life Care

Approval:         Jennifer Strus, Assistant Secretary

Original Date:  October 31, 2016

Revised Date:  Not applicable

Policy Review: October 31, 2020


To provide guidance when a child’s medical provider makes a recommendation to begin making end-of-life decisions for a dependent child in out-of-home care. This policy does not apply to a child in tribal custody or youth in Extended Foster Care.


Do-not-resuscitate (DNR) order is a medical order written by a doctor. It instructs health care providers not to perform cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. A DNR order is created or set up before an emergency occurs and allows an individual to choose whether or not he or she wants CPR in an emergency.

Hospice care is supportive care provided to people in the final stage of a terminal illness focusing on comfort, quality of life and being free of pain rather than a cure.


This policy applies to Division of Children and Family Services staff.


RCW 74.13.031 Duties of the department, child welfare services and children’s services advisory committee


  1. When a child’s medical provider makes a recommendation to begin making end-of-life decisions for hospice or the issuance of a DNR order the caseworker will:
    1. Immediately notify his or her supervisor and the regional medical consultant (RMC).
    2. Notify the following individuals of the medical provider’s recommendations:
      1. Child’s parents and parent’s attorney, if the child is not legally-free
      2. Assistant attorney general (AAG)
      3. Child’s out-of-home caregiver
      4. Guardian Ad Litem (GAL)/Court Appointed Child Advocate (CASA)
      5. Child’s attorney, if assigned
    3. Document efforts made to locate the parent in FamLink if the parent of the child cannot be located.
    4. Contact the child’s tribe if the child is a member of a federally recognized tribe to determine their role in making end-of-life decisions.
    5. Conduct a shared planning meeting if any party to the case disagrees with the medical provider’s recommendations
    6. Assist the child’s family and caregivers to identify community based services and supports that address grief and loss.
  2. AAG consultation is required if organ donation is proposed.


  1. When conducting a shared planning meeting, the discussion must include what is in the best interest of the child and whether court approval is necessary to implement the recommendations.
    1. Invitees must include the following:
      1. Child’s parents and parent’s attorneys, if the child is not legally-free
      2. AAG
      3. CASA/GAL
      4. RMC
      5. Child’s attorney, if assigned
      6. Out-of-home caregivers; even though they are not parties to the child’s case.
    2. Consult with the medical provider regarding how to involve the child and ensure the child’s wishes are represented at the shared planning meeting. This includes determining whether it is in the child’s best interest and if he or she is physically able to participate in the meeting.
    3. If the medical provider determines the child is developmentally appropriate and physically able to participate, work with the child’s medical provider to determine if the child wants to attend the meeting.
    4. If the child chooses to attend the meeting, make arrangements to accommodate his or her needs as appropriate.
  2. When court action is pursued to obtain approval of the medical provider’s recommendations regarding the child's end-of-life care, the caseworker must:
    1. Consult with AAG to determine appropriate steps for seeking court approval of the recommendations.
    2. Work with the RMC to obtain the following documentation and attach to the motion:
      1. A written statement from the medical provider who is recommending hospice care or the issuance of a DNR order. The statement from the provider must include statements from two additional medical providers qualified to assess the patient’s condition indicating with reasonable medical judgment that the patient is an advanced stage of a terminal and incurable illness and is suffering severe permanent mental and physical deterioration;
      2. The child’s medical history including the child’s current condition, diagnosis and prognosis;
      3. Any supporting documentation provided by the medical provider to support his or her recommendation including that the recommendation is in compliance with the hospital’s ethics protocol, if applicable;
      4. Parent’s recommendation or concerns, if applicable (if child is not legally-free); and
      5. Child’s opinion about his or her desire to enter into a DNR order if the child expressed an opinion. Include when, where and how the child made his or her wishes known. The child’s wishes must also be documented in a case note.
    3. Provide the date and time of the court hearing to the:
      1. Child’s parents and parent’s attorney, if the child is not legally-free.
      2. Child if developmentally appropriate and physically able to participate.
      3. Child’s attorney, if assigned
      4. Out-of-home caregivers
      5. GAL/CASA
    4. If the parent of the child cannot be located, document efforts made to locate the parent in FamLink.
  3. When a child’s medical professional recommends end-of-life care, the supervisor will:
    1. Inform his or her area administrator of the medical provider’s recommendation;
    2. Confirm that the caseworker is consulting with the RMC;
    3. Verify with the caseworker that all parties to the case have been notified; and
    4. Assure the caseworker has identified and referred the family and caregivers to any needed support services addressing grief and loss.


Guidelines for Reasonable Efforts to Locate Children and/or Parents (on CA intranet)


Your Rights Your Life A Resource for Youth in Foster Care

End of Life Care Notification and Shared Planning Meeting Table