What would you do...

[Richard B the EMT]

We suspend DNR orders during surgery for this reason.

I must have missed something, here.

Is not surgery considered an invasive procedure not allowed under a DNR order in the first place?

[HERBIE1]

I must have missed something, here.

Is not surgery considered an invasive procedure not allowed under a DNR order in the first place?

What if it's surgery to fix a fractured foot, debride an ulcer, or implant a catheter to administer pain medication?

DNR's aren't exclusively used for terminally ill patients either. Many of us have advanced directives(dealing with feeding issues, organ donations, funeral arrangements, etc and a DNR is simply part of that package.

[Doczilla]

A DNR is not absolute, and still requires some critical thinking. If an old lady with a DNR broke her hip, would you let her spend the rest of her days unable to walk, bed confined, and in pain every time she moved for want of a hemiarthroplasty? This is an invasive procedure, requiring general anesthesia, but will immeasurably improve her quality of life. Would you not treat a UTI, which is usually fairly easily done with oral antibiotics, and let her wallow with pain and fever? This measure is "artificially prolonging life", but we do it quite a bit because it is "low hanging fruit".

There are two types of DNR orders in Ohio. The DNR-Comfort Care means just that: comfort care only. This has been interpreted to include antibiotics, pain medication, artificial hydration and feeding. The DNR-CCA in its most basic form means that you do everything but CPR. There is still wide variety in what people will ultimately want done, so if it is not spelled out in an Advanced Directive, we have to decide based on information about the patient from loved ones, what the procedure or treatment will ultimately do for the patient, and prognosis of their various medical problems. It is not as cut and dry as a check box on a piece of paper.

'zilla

[JakeEMTP]

Here in the Tarheel State, we have 2 similar yet different forms regarding DNR. One is the DNR itself. It states that in the event of a cardiac arrest/pulmonary arrest, we are not to initiate CPR.

http://www.ncdhhs.gov/dhsr/EMS/pdf/DNR.pdf

The Other is a newer form called a MOST (Medical Orders for Scope of Treatment) which outlines to what level of interventions are to be preformed and is filled out by the patients PCP, signed by the patient, family and the Physician. It seems to work pretty well in eliminating the "grey" area.

http://www.ncdhhs.gov/dhsr/EMS/pdf/ncmostform.pdf

[CBEMT]

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.

Our protocol is called "Comfort One."

I have, but depending on your interpretation of the protocol, I may have done so in violation.

The Comfort One protocol is a set of standardized, state-wide patient care orders to be followed by

emergency medical services personnel when encountering a Comfort One patient. The protocol emphasizes

that the patient will receive palliative, supportive care; but no resuscitative measures.

A Comfort One patient is a patient who:

Has executed a Living Will and/or Durable Power of Attorney; and

Has been diagnosed as having a terminal condition; and

Has been issued a Comfort One bracelet.

This designation also applies to patients having a physician authorized Do-Not-Resuscitate (DNR)

Order recorded in the patients medical record or a DNR order received directly from a physician in

compliance with theMedical Control at the Emergency Scene protocol.

Problem being, the out-of-facility patients almost never have the bracelet. Hospice is famous for having all the paperwork at their inpatient unit and nothing at the house. Last time I encountered a braclet, it was sitting on the nighttable next to the patient's bed.

Most CO/DNR patients we encounter are nursing home residents with facility DNRs, none of which are ever the same and frequently have a "menu" of possible choices- Yes to hydration, no to hospitalization, yes to CPR, no to intubation... you get the idea. So the issue now becomes, do we treat according to "signed DNR status," which initiates Comfort One and everything it prohibits, or do we treat according to the patient's menu selections? Especially if they're still alive?

3. Upon verification of Comfort One status:

DO NOT:

Initiate CPR

Administer chest compressions

Intubate (ET or EOA)

Initiate cardiac monitoring

Start an IV for resuscitation

Administer cardiac resuscitation drugs

Defibrillate

Provide ventilatory assistance

DO (as indicated by the patients condition):

Suction airway

Administer oxygen

Position for comfort

Splint

Control bleeding

Provide emotional support

If possible, determine if hospice or home health agency patient and contact appropriate agency.

Contact the patients attending physician or Medical Control for further orders.

Several people have said that their DNR protocol says that they cannot cardiovert. Does this apply only to electrical cardioversion or does it include chemical cardioversion?

For me, I suppose that depends on how you define "cardiac resuscitation drugs."

DNR orders vary by individual and what treatment they had in mind. In my mind, resuscitation includes aggressive administration of iv fluids.

Great, now I can't even start an IV on our crumping DNR!

Jake- I like your form a lot better than I like my whole protocol.

Edited September 6, 2010 by CBEMT

[Richard B the EMT]

DNR's aren't exclusively used for terminally ill patients either.

Oops, I had forgotten that. My apologies to the group

[Lone Star]

Problem being, the out-of-facility patients almost never have the bracelet. Hospice is famous for having all the paperwork at their inpatient unit and nothing at the house. Last time I encountered a braclet, it was sitting on the nighttable next to the patient's bed.

It's always been my understanding that if you cannot be provided with a physical copy of a valid DNR, you must proceed as if there were none at all.

It's been drilled into our heads time and time again that we MUST verify it's validity (signature of both patient and physician, current dates, specifies extent of treatments denied, etc.). If we cannot personally inspect that document, we can't take anyone's word for it that one exists.

[JPINFV]

It's always been my understanding that if you cannot be provided with a physical copy of a valid DNR, you must proceed as if there were none at all.

As with everything, it is all dependent on the local procedure for following DNR orders. I know of areas that allow EMS providers to honor verbal requests from immediate family members to withhold or withdraw resuscitation.

[HERBIE1]

As with everything, it is all dependent on the local procedure for following DNR orders. I know of areas that allow EMS providers to honor verbal requests from immediate family members to withhold or withdraw resuscitation.

That is scary(verbal DNR), and something I would not want to deal with. I see HUGE potential problems with family disagreements. Even with a written DNR, there may be conflicts within a family, but at least you as a provider, that written DNR covers your arse.

[JPINFV]

That is scary(verbal DNR), and something I would not want to deal with. I see HUGE potential problems with family disagreements. Even with a written DNR, there may be conflicts within a family, but at least you as a provider, that written DNR covers your arse.

Family disagreement on scene means resuscitate and call medical control (which means call paramedics if you're an EMT). On the other hand, when both the husband and son are on-scene and requesting no resuscitation on an end stage lung cancer patient who's on home care and they can't find the DNR, that could very much mean the difference between going to the patient's home hospital and a fast trip to the ER down the street (my partner thought it looked worse than it was in my opinion ). It's nice to have the option (since boiler plate "anything questionable means call medical control" applies) than tell a family, "Opps, sorry you messed up, now you have to go sit in a strange ER and hope they can transfer to your home facility because you can't find the DNR."

If you'd like to read the DNR policy, here it is. Top of page 3 is where the clause about immediate family members is.

http://ochealthinfo.com/docs/medical/ems/P&P/330.51.pdf

Edited September 7, 2010 by JPINFV