What would you do...

[tcripp]

I was having a discussion with a peer on a hypothetical situation and thought I'd bring it here to see what you think.

You have an elderly patient who is 97yo, her b/p is 107/84, RR 23, pulse is 182. (Pulse stays between 180 - 190).

She is A&Ox2. Her GCS is 14 (4/4/6) and she doesn't express that she is in any pain. ECG show SVT. She has an active OOH DNR.

Attempting to do vagal maneuvers is difficult - so you decide to give adenosine as per your protocols.

The adenosine puts her in to cardiac arrest. Do you honor the DNR or do you begin resuscitative measures since you, technically, caused the cardiac arrest?

Again...this is hypothetical. I'm just curious as to what you'd do?

[JPINFV]

DNR means DNR. On one hand, witness arrest with a shockable rhythm, I could see the argument to give a defib or two. However if you get ROSC and the patient ends up on a vent, then we start getting into bad juju territory.

[FireMedic65]

That is a touchy situation, but as JP said, a DNR is a DNR. Giving adenosine per protocol, patient goes into arrest. What about if the patient went into arrest when you attempted vagal? What about if they went into arrest spontaniously? Your treatment may have caused it or it may not have. This could fall into the same situation when any DNR patient. If you come on scene for lets say.. chest pain, during treatment, the patient codes. If you are presented with a DNR (before arrest), you stop. If you are showed the DNR after the arrest and already doing CPR.. call command.

When in doubt, call medical command.

[Just Plain Ruff]

Medic induced DNR compliance.

call medical control - say you gave adenosine, she coded, she has a dnr what do you want to do.

Isn't the first rule of medicine to Do No Harm?

[HERBIE1]

Not to play semantic games here, but I would also verify exactly what that DNR said. Was it no advanced interventions, no CPR, no defib, no intubation, no pressors?

I would start CPR and immediately call medical control. Let them decide if you discontinue CPR and honor the DNR.

[fiznat]

Step 1: Curse, defecate in pants.

Step 2: Call medical control, who will almost definitely tell you to honor the DNR.

Step 3: Worry. Hope that nothing comes of it even though you did nothing wrong.

Edited September 1, 2010 by fiznat

[Just Plain Ruff]

Step 1: Curse, defecate in pants.

Step 2: Call medical control, who will almost definitely tell you to honor the DNR.

Step 3: Worry. Hope that nothing comes of it even though you did nothing wrong.

fiznat hits the nail on the head

they called cause she probably wasn't feeling well. She had stable vitals other than a rapid heart rate.

We do vagal and nothing happens (so far no harm)

WE decide to do adenosine and we cause her to code (we did harm) even though we know this is sometimes the outcome of adenosine

We now have moved her from stable to dead. I think the family might have a bit of a problem with this.

So how do we deal with this situation. She has a DNR, the doctor agrees that we honor the DNR. We don't code her and she passes away.

I can see the family and their point of view, that we killed granny. Just how do we get ourselves out of this sticky situation? I hope it never happens to any of us here but it does and has to some.

How do we extricate ourselves from this situation? I think that is the next question that we have to answer.

What do you tell the family?

Do you request a supervisor or what?

[JPINFV]

Here's my big problem with contacting medical control with this. How long will it take to realize that the patient is in arrest, defecate, realize you need medical control because of the DNR, contact medical control, get the physician on the radio, rely the situation, and get an order? All the while the likelihood of a good outcome diminishes. While I wouldn't have to explain that I 'killed Grandma,' I'd much rather explain that then explain why Grandma is now on a vent in ICU.

[Linuss]

I could have SWORN I remember being told a cardiac arrest caused by something we did still gets worked, because it's not a "natural" cause of death, which a DNR is supposed to be for. Just like "suspicious" circumstances surrounding a code with a DNR... you still work it.

Though I can't find it in protocols, be it from my company or others....

Edited September 1, 2010 by Linuss

[ERDoc]

In most jurisdictions, if you start CPR, despite a DNR, you will not be faulted. If you do what you think is in the best interest of the pt, you will be okay. That is not to say the family won't be upset. I've been in the situation a few times (though not with the Adenosine). It sucks to watch someone go from talking and breathing to dead in seconds. As a provider, it is your nature to want to do something but you just have to put your hands in your pockets and resist the urge. I would say that for prehospital providers, your best plan is to contact medical control, just to CYA.