"Less Than Perfect" DNRs

[Tigger]

You are called to a cardiac arrest. You find the patient to indeed be pulseless and apneic but still viable enough to begin resuscitation. For the purpose of discussion, you one of the following on or near the patient:

A bracelet/dog tag that says DNR on it (your state laws do not explicitly allow for this).

A proper DNR form, but one that is not 100% completed.

A properly completed DNR form that is lacking the patient and/or physician's signature.

A hand written note signed by the patient requesting no heroic measures.

I could go on, but I am sure you see what I am getting at.

Part 2:

There is no physical evidence of a DNR, however the patient's immediate family all state that the patient would not wish to be resuscitated.

How do you proceed? Do the obvious signs of comorbidities sway your decision?

Also, if you feel so inclined, check out the poll!

 

[DesertMedic66]

Yes for part one.

As for part 2, we are not allowed to follow families wishes. I would definitely be on the phone with the ED. The odds are I would be working them and transporting.

 

[RocketMedic]

Seriously depends on the context and exactly what's wrong. If we're working a 91 y/o terminal cancer patient on hospice with Cancer of Everything, a crying wife, a lawyer for a son requesting no heroic measures, I honestly would feel OK calling medical control and explaining to them even without a DNR, and when the above happened to me with a DNR missing a doctor's signature and an appointment scheduled for 2 days later, I was entirely comfortable halting the code, just as I have at nursing homes where the facility has DNR markers over beds while the master copy was fetched.

Working everything in a full-court press for lack of documentation is a little silly. Everything is circumstantial and contextual.

 

[RocketMedic]

With that being said, things that look shady or odd need better than "he said".

 

[ZombieEMT]

My person opinion is that this patient should not be worked and a pronouncement should be made. Unfortunately, I can no go on my personal opinions and/or feelings. According to my state guidelines, this is a workable code. Not providing CPR can turn into a legal situation and be considered neglect.

 

[EpiEMS]

System protocols would necessitate the performance of "full" resuscitative measures in both cases. However, ideally, I'd call medical control for the first one. My expectation is that they'd require us to work it and transport it. Ethically, I would have a problem with performing resuscitative measures on both patients, especially if it came down to the MD happening to not sign the DNR or something as silly as that, and especially especially if the patient was suffering from a terminal illness or was totally incapacitated prior.

Would love to hear from some EM physicians on this, that's for sure!

 

[Ewok Jerky]

Wholly situation dependent. In general I am a stickler for the law so in most cases I would be working it if there is any doubt. Except for the aforementioned 90 y/o terminal CA pt

 

[NomadicMedic]

Every instance I've had a pulseless and apneic patient that presented as you've detailed above, a call to medical control on a taped line has resulted in a pronouncement.

There may be a short period of CPR while we sort things out, but no advanced interventions. I've never had to work a code when the family related that the patient would not want a resuscitation.

 

[Rin]

I'd have to work both.

I have met hospice patients that do not have a DNR. Sometimes end-of-life patients are not ready to stop fighting.

 

[Tigger]

Every instance I've had a pulseless and apneic patient that presented as you've detailed above, a call to medical control on a taped line has resulted in a pronouncement.

There may be a short period of CPR while we sort things out, but no advanced interventions. I've never had to work a code when the family related that the patient would not want a resuscitation.

This has been my experience as well. We'll keep doing BLS until we can get can get a pronouncement, but that' it. Even with no DNR form, we get a pronouncement. If I thought there was something suspicious I might consider not doing that. But generally speaking, when it comes to someone that is dying, the family is on the same page.

 

[Sunburn]

A bit tricky. Yeah, in 91 y/o case I would, and indeed have not begun CPR. But in the cases where the patient has no immediate terminal illness and where resuscitation would not just prolong suffering and only the family or incomplete docs claim DNR I would feel obliged to circumvent those wishes and resuscitate the patient if I am able.

Imagine if you will a family that ODed their grampa for insurance or inheritance and slapping together a haphazard DNR. As farfetched as it seems you must assume it is possible and discard incomplete or suspicious DNRs. It's a shame and extremely brutal practice but unfortunately that's the way things are.

 

[Tigger]

A bit tricky. Yeah, in 91 y/o case I would, and indeed have not begun CPR. But in the cases where the patient has no immediate terminal illness and where resuscitation would not just prolong suffering and only the family or incomplete docs claim DNR I would feel obliged to circumvent those wishes and resuscitate the patient if I am able.

Imagine if you will a family that ODed their grampa for insurance or inheritance and slapping together a haphazard DNR. As farfetched as it seems you must assume it is possible and discard incomplete or suspicious DNRs. It's a shame and extremely brutal practice but unfortunately that's the way things are.

Suspicious is one thing, though I don't think that there is much of a problem with people being murdered by way of DNR...

As for incomplete, that's not much of an issue for me.

 

[Sunburn]

OK, murder by DNR is one thing, but would you resuscitate a 35 y/o that you found hanging by the neck from the rope, still warm and viable with a hand written DNR pinned to his shirt?

 

[NomadicMedic]

OK, murder by DNR is one thing, but would you resuscitate a 35 y/o that you found hanging by the neck from the rope, still warm and viable with a hand written DNR pinned to his shirt?

That's a totally different scenario than what's posted above.

 

[VFlutter]

From an ICU perspective it really is a shame when these patients are coded. The majority of these patients end up in the ICU vented, on pressors, etc with no chance of recovery for days until the family decides to withdraw. It is much harder for families to withdraw on these patients once it has started even when they know "they wouldn't have wanted any of this".

 

[EpiEMS]

From an ICU perspective it really is a shame when these patients are coded. The majority of these patients end up in the ICU vented, on pressors, etc with no chance of recovery for days until the family decides to withdraw. It is much harder for families to withdraw on these patients once it has started even when they know "they wouldn't have wanted any of this".

And the burden on the system! It's not cheap, that's for sure!

(And I distinctly recall seeing a study of physician end of life care preferences vs. the general population -- it showed that physicians tend to want much less in the way of interventions, especially if otherwise terminal. There's something to be said for incomplete information, here.)

 

[Sunburn]

That's a totally different scenario than what's posted above.

From medical standpoint absolutely. From legal standpoint, not as much.

Don't get me wrong, I'm absolutely against unnecessary resuscitations and prolonging of suffering, but in those situations you have to cover your own bum first.

 

[RedAirplane]

These are the type of situations that I'm afraid of.

 

[Rin]

They're definitely not fun situations, having to explain to a patient's family that their DNR is invalid. It's not even a complex form. It floors me that doctors etc can't be bothered to make sure they fill out such an important thing correctly. It's like a check box, a signature, and a date. Come on, guys.

 

[Kevinf]

My favorite one was when a doctor signed the line for a pregnant DNR, for a 50 year old male.