A DNH

[dahlio]

A friend of mine was telling me about a call to a nursing home. The patient who had chest pains (according to the dispatch), had a DNH and a DNR, according to the Nursing staff, who then showed him the orders. Since the patient was the one calling, and not the nursing home...what do you do? Thoughts please, thanks.

[brentoli]

Sorry, whats a DNH?

[dahlio]

Sorry, whats a DNH?

Do Not Hospitalize, from what my friend told me. I've never had experience with one however, which is why I'm asking the question.

[VentMedic]

The reason prehospital people don't see DNHs is because the patient doesn't get transported to the hospital. They die at the facility, hopefully in comfort or pallative care.

Inside the hospital we have an order similiar in context "Do Not Send to ICU".

DNH orders are not that common depending on the state you are in. Often the DNR contains the specifics and a separate DNH form is not necessary. Some states frown on DNH orders if worded too loosely and specifics must be included. They are usually meant for long term facilites. Again there are exceptions that may be made for DNH orders such as going to the hospital for suctures or x-rays post fall. If the person is having a problem that is not related to their terminal illness, then they can still be hospitalized.

For this particular call concerning chest pain made by the patient, I would probably ask if the physician had been called or call him/her myself for a name to add to my documentation. The patient may have a terminal cardiac disorder, dementia or may even have an acute cause for confusion that needs to be corrected. If the patient's normal state is confusion or dementia, I would ask about access to the telephone since 911 is the easiest number to remember and called frequently by residents of nursing homes. Dispatchers usually try to verify these calls with the facility's nursing station if possible.

[paramedicmike]

The patient called and said, "Help me!"? Is that right?

If that's the case, then you do what the patient wants. Even if that means flying in the face of the DNR/DNH orders present. So long as the patient is competent enough to make decisions him/her-self, that patient can revoke any orders in existence. This includes DNR/DNH orders.

Are you really going to stand there and tell a completely competent patient, a patient who has just asked for help, "I know you want to go to the hospital but I'm sorry. You have this DNH order and I have to abide by it."? If you answer "yes", then please leave your cards by the shredder as you leave for a new line of work.

-be safe

-be safe.

[riskynremtp]

I think Paramedicmike summed that up quite well.

[VentMedic]

The patient called and said, "Help me!"? Is that right?.

These are the only words heard in many nursing homes, hospitals or psych wards after the sun goes down. And, if patients get their hands on a telephone, they will call 911.

That is why the doctors and judges make the big bucks to give guidelines on mental capacity and competency to make decisions. If a patient is competent or with mental capacity they can revoke the DNR/DNH as can their DPOA. If a patient has drug induced confusion from all the comfort care medications, it is nice to have a doctor, either the PCP or your medical director covering your back. A telephone call placed to your medical director and the PCP while you're doing your assessment could save all a lot of grief later. Patients in comfort care are supposed to die peacefully but sometimes it doesn't work as well as planned due to their built up tolerance to the pain medications from months or years of suffering. The healthcare providers may have under medicated and allowed the patient to experience too much pain. Death is also frightening to some near the end. That is why specific orders need to be written and carried out by well trained/informed individuals.

If that's the case, then you do what the patient wants. Even if that means flying in the face of the DNR/DNH orders present. So long as the patient is competent enough to make decisions him/her-self, that patient can revoke any orders in existence. This includes DNR/DNH orders.

DNR orders are revoked all the time. If a patient is in Hospice, often times they have to revoke their DNR to have transport to the hospital for various procedures or treatment for a non-terminal illness related event. Alot of this has to due with insurance and not necessarily the patients wishes. Some Hospices do not require DNR/DNHs. This is expecially true of the Hospices that cater to AIDS patients that do not require DNRs.

So yes, a patient can revoke their DNR. But, it's nice to have the facts before you make a blanket statement on every situation.

[paramedicmike]

I'm not sure if you're disagreeing with specific items, uncomfortable with what I said, or are just clarifying. There's a lot involved with what I posted that I left unsaid...specifically along the lines of a competent provider figuring out what's going on and gathering those facts before making any kind of decision.

The bottom line, though, is that regardless of the situation, a competent patient can revoke any valid DNR/DNH order that exists. Whether the motivation be fear, tolerance to pain meds or whatever, they can still revoke the order if they're competent. Now, determining competence is part of what we do on scene. That determination can be made with the help of a variety of sources and in consultation with a wide variety of people and may not be the decision of a single person. But if everything adds up and they want to revoke the order, the order is revoked.

I might not think it's the best decision given the circumstances. The docs involved might not think it's the best decision given the circumstances. But it's not about me. It's not about the docs.

I don't think we're really disagreeing. It might be hard to tell given the limitations of the typed word. Just wanted to make sure.

-be safe

[VentMedic]

True, we agree on most points with the DNR. However, if there is a DNH form also present, that means there was extended discussion with the patient and/or their DPOA. There could also be an Ethics Committee involvement possibly by the same hospital to which you will be transporting. A call either by you or the nurse to the PCP is courtesy since he/she had to do careful documentation on this DNH order. The physician may meet the patient at the hospital to discuss the patient's needs and to ensure the patient fully understands what will happen next. Although, sometimes all it takes is a trip to the hospital to remind the patient why they signed their DNR and/or DNH especially if they are placed near the resuscitation room with a ventilator patient.

[paramedicmike]

That's all true. An experienced provider would make sure that every step is taken to ensure the patient knows what's coming. S/he will also work to ensure that the people who need to know find out. But in the end it still stands if the patient is capable of making his/her own decisions the order can still be revoked.

It might create headaches on everyone involved from the patient to the family to anyone providing any type of care. But that takes us back to the original point. Despite *everything* else, a competent patient can still revoke an order made in his/her name. We may look at all the hassles involved and all the work completed to take everything to that point but if that's what they *really* want they still have that right.

We're probably looking at this from two different angles and seeing the same thing.

-be safe