What would you do...

[FireMedic65]

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.

I have treated a patient and watched them code in front of my eyes. I started CPR, knowing the DNR was present. I did not however, read the DNR to see what it was stating before I started treating their chest pain. When I walked in.. the patient said "help me".

[HERBIE1]

I have treated a patient and watched them code in front of my eyes. I started CPR, knowing the DNR was present. I did not however, read the DNR to see what it was stating before I started treating their chest pain. When I walked in.. the patient said "help me".

That's all they need to say. The paperwork is meaningless at that point.

[CBEMT]

Not applicable. If I'm following our DNR protocol, I never applied the monitor. Ergo, I don't know she's in SVT.

O2 and transport. Let the hospital decide if they want to do something about it.

If we assume that I did apply the monitor, I now have to decide if adenosine is a "cardiac ressucitation drug," because if it is I can't start an IV to give it.

[Just Plain Ruff]

Not applicable. If I'm following our DNR protocol, I never applied the monitor. Ergo, I don't know she's in SVT.

O2 and transport. Let the hospital decide if they want to do something about it.

If we assume that I did apply the monitor, I now have to decide if adenosine is a "cardiac ressucitation drug," because if it is I can't start an IV to give it.

So you don't put a monitor on any DNR patient?

You must have pretty strict DNR protocols.

If the patient isn't coding then the DNR does not apply at least to my knowledge it doesn't. DNR's are not Do not treat's they are do not resuscitate and from the original scenario it sounds like she was stable other than a heart rate of 180+ I don't think the DNR applies at this particular point in time.

[Linuss]

Here we go, per the Texas DSHS FAQ on DNRs

DNR ONLY applies to CPR, Pacing, Defibrillation, Advanced Airways and Artificial ventilation...no mention on cardiac drugs, just electricity.

Also, healthcare professionals do NOT have to honor a DNR if "There are unnatural or suspicious circumstances surrounding the death." which you can argue giving adenosine and causing arrest is unnatural.

Granted, this is just my state for OOH-DNRs (which the OP lives in the same state) and I'd still call MC while CPR is being done.

Edited September 2, 2010 by Linuss

[HERBIE1]

Not applicable. If I'm following our DNR protocol, I never applied the monitor. Ergo, I don't know she's in SVT.

O2 and transport. Let the hospital decide if they want to do something about it.

If we assume that I did apply the monitor, I now have to decide if adenosine is a "cardiac ressucitation drug," because if it is I can't start an IV to give it.

I'm confused- how is applying a monitor breaking a DNR order? It's simply a tool to check vital signs, but electricity or meds based on what you see is a whole different ballgame.

[Lone Star]

Also, healthcare professionals do NOT have to honor a DNR if "There are unnatural or suspicious circumstances surrounding the death." which you can argue giving adenosine and causing arrest is unnatural.

If following protocol results in 'suspicious circumstances surrounding death', isn't that pretty much the same as saying, "Yeah, we killed the old bird."?

Since you are the cause of the 'suspicious circumstances' surrounding the death of this woman, (and you've essentially admitted to being the cause), aren't you setting yourself up for criminal prosecution as well as setting the company up for civil liability?

As far as not applying a monitor, I'm just as confused as everybody else. How can you even begin to think you're geting a 'clear picture' of what's going on with the patient if you don't use the diagnostic tools at hand?

In reference to the post where the patient had a valid DNR and said "Help me!", I have to agree, that simple statement completely negates the DNR, even if the ink on it isn't dry.

[wrmedic82]

If following protocol results in 'suspicious circumstances surrounding death', isn't that pretty much the same as saying, "Yeah, we killed the old bird."?

Since you are the cause of the 'suspicious circumstances' surrounding the death of this woman, (and you've essentially admitted to being the cause), aren't you setting yourself up for criminal prosecution as well as setting the company up for civil liability?

As far as not applying a monitor, I'm just as confused as everybody else. How can you even begin to think you're geting a 'clear picture' of what's going on with the patient if you don't use the diagnostic tools at hand?

In reference to the post where the patient had a valid DNR and said "Help me!", I have to agree, that simple statement completely negates the DNR, even if the ink on it isn't dry.

I doubt this would be a subject to criminal prosecution on the basis that the provider not only did what was felt to be best for the Pt, but also as indicated for the situation by protocol and accepted ACLS algorithm . Although it may have caused the arrest, if nothing was done it could be argued she would have died anyway. Who knows what underlying cause of her SVT was? Epidural head bleed maybe?

I can see how not placing the monitor on the Pt adopts the "ignorance is bliss" notion for DNR pt's, however I would look into your states laws on OOH DNR's before putting this into your medical practice. As stated earlier in Texas (where I live) it only states we cannot do CPR, Shock (defibrillation, pace, cardioversion) or perform advanced airway. Says nothing about monitoring. Everywhere is different.Besides I personally wouldn't want to say "I dont know" to a doc or a nurse if I could have taken the time ahead to find out everything I could about the Pt before handing over care.

Just a side note to my two cents, remember there is two of you on a truck. You can pull over and utilize that person to do CPR or contact med control. Dont handicap yourself. Half @#! CPR is as good as no CPR.

[tcripp]

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.

Very interesting comments from everyone...some more than others.

Herbie...thanks for actually using the word "I" in your response. Since the question was, "what would you do" and not" what should I do"...I appreciated reading your answer.

[HERBIE1]

Very interesting comments from everyone...some more than others.

Herbie...thanks for actually using the word "I" in your response. Since the question was, "what would you do" and not" what should I do"...I appreciated reading your answer.

Welcome. The problem is, in a scenario, with so many different local protocols, often times there is more than one "right" answer. What I may be able to do may contradict protocols in your area.