DNR/Advanced Directivies.

[emtCstock]

I agree with fire, if they do have a valid DNR I would not resuscitate, if they are getting hostile, move the patient to the unit and call PD. California is pretty stern on DNR's as well as local protocols, you have to take those into effect.

 

[emtCstock]

Agree with Firefite*

 

[JPINFV]

I agree with fire, if they do have a valid DNR I would not resuscitate, if they are getting hostile, move the patient to the unit and call PD. California is pretty stern on DNR's as well as local protocols, you have to take those into effect.

So... you'd ignore your LEMSA's (Fresno County is a part of the Central California EMSA group) policy for handling DNRs after talking about taking local protocols into consideration?

B. If the patient is conscious and states that he/she wishes resuscitative measures, the DNR order shall be ignored. If the patient is unable to state his/her desires, and the patient's legal representative or conservator (if patient legally incompetent) or a family member is present who wishes resuscitative measures be provided, resuscitation shall be undertaken, since such person's objection may raise questions about the validity or applicability of the DNR order. It is important to remember, however, that the patient ultimately has the right to determine the course of his or her own medical care. In situations where the DNR order does not seem to apply, then EMS personnel shall not honor the order and shall immediately initiate basic CPR and contact a Base Hospital for direction.

Emphasis added
http://www.co.fresno.ca.us/uploaded...,_Kings_and_Madera_Counties/500_-_699/564.pdf

...and to be clear, if you want to make an argument outside of protocols then by all means do so. However I don't think it's legitimate to say, "I wouldn't do X, but follow your protocols" when your own protocols says to do X.

 

[OrlandoRMAMedic]

our protocols state that if there is any question about the validity of the DNR. I thought that there had been mention about family member input, but it says, and I quote
"♦ When presented with a State of Florida Yellow DNR Form 1896 or State of Florida Yellow DNR Device which is a miniature copy of DNR Form 1896
The form must be properly completed, including physician signature.
♦ If unknown DNR status or question of DNR status, initiate resuscitation
Note: A Living will is not equivalent to a DNR form and resuscitation is required unless the above criteria are met."

I just learned something new. It may have been the protocols to my volley county that has that in there... now I am going to have to go find those and look it up. I have never been faced with an issue like this. Most of my DNR pts are in a nursing facility of some sort or in hospice.

** I found the other counties protocol online and it falls in line with the county that I get paid to work in

"Terminally ill patients present ethical and legal questions when making resuscitation decisions. Frequently, surviving family members will direct that resuscitation should not be attempted. The questions associated with the “Death with Dignity” issue are important, emotional, and beyond the ability of an EMS system to address.
A. The State of Florida’s “Do Not Resuscitate Order” (DNRO) form will be honored as long as the form is either an original or the form is a copy on yellow paper. The form must be complete and signed. If there is doubt of the authenticity of the form or the form is not a State of Florida DNRO form, resuscitation will be performed on the patient unless another section of this protocol applies.
B. If a patient does not have a DNRO, but is terminally ill, decrepit, and in the end-stage of the disease process, contact medical control for orders to cease resuscitation."

 

[Smellypaddler]

So then it stands to reason that if a patient becomes incapacitated due to a medical condition (say, intubated, sedated, and being treated in the ICU), the physician makes all medical decisions without input from the immediate family until the court appoints a medical power of attorney?

Shocking but true.

The treating physician makes decisions about patient care. Those tricky decisions such as turning off life support etc go before an ethics committee at the hospital.

A family member or next of kins wishes are considered but have no legal standing.

 

[KellyBracket]

This sounds a lot like the scenario that some Texas medics faced in '08.

This can be a thicket of issues; legal, ethical, medical, and perhaps most importantly, practical. There is an opportunity to get things real wrong if you try to analyze things in a hectic environment, and this hardly applies only to EMS.

There is a tremendous opportunity to screw things up on these things, and EMS should not feel like they have to make the final call on their own.

Sounds like I should tackle this issue, with an emphasis on Connecticut policies, in my next blog post!

 

[JPINFV]

There is a tremendous opportunity to screw things up on these things, and EMS should not feel like they have to make the final call on their own.

The final call? I agree, EMS shouldn't have to make it alone. However, EMS providers have to make the first call, and there's only one option available for the first call that allows for consultation before making the final call.

 

[triemal04]

1a) You arrive, the patient was a witnessed arrested. Same as above, signed DNRs but the family is frantic and becomes agitated and aggressive towards you and your partner.

2) Witnessed arrest, before the patient went into arrest, the family state he said "Don't let me die, I don't want to die yet". Pt has signed DNR.

I'm just seeing what anyone eles opinions/thoughts are on these. I find it somewhat difficult at times. Its a legal document, and you have to respect the patients wishes.

The first two are the same. Make an attempt to explain to the family what is going on, why it is happening, and that you are following the patien'ts wishes. Remember that this is a terrible moment for them, and they really are your patients now. If needed, back out, call for a police responce, making sure that they know that it's not for an emergent problem. And take the DNR with you.

The third...punt that one. Start basic CPR, get as much info as you can about the patient's medical history and why they have the DNR in the first place, and then make a discrete phone call to whoever your medical control is.

In each case, be very sure that it really is a valid DNR. (in this area there is a push to have them on the refridgerator door) And woe to you if you live somewhere where a family member can retract a patients advance directives.

 

[Nervegas]

I can see where a living will would get into a grey area, but in TX if I am presented with a valid DNR, or they have an OOH-DNR identification tag/bracelet etc, I can honor it. Only the patient can revoke that DNR, regardless of what the family says. If a family member tells me that with their dying gasp they revoked the order I can still honor the original DNR - "(d) Except as otherwise provided by this subchapter, a person is not civilly or criminally liable for failure to act on a revocation made under this section unless the person has actual knowledge of the revocation."

When in doubt, contact OMC and discuss it with them.

 

[DrankTheKoolaid]

re

In all three cases I would not begin resuscitation. If family is agitated I would move patient to the rig and leave for safer grounds while law enforcement was dispatched.

My first field save was a cancer patient that I knew for sure would have been a DNR, but the transporting VFD that met us with the patient did not bother to look for or find out if patient was DNR. Quick hand off and away we went. During the 30 minute transport to the ED patient coded on me and ROSC was achieved... Upon arrival at the ED patient is still altered and within 5 minutes patient is talking and the first question the MD asked was do you have a DNR signed. "Yes I do" Talk for a few minutes and when he found out he was resuscitated he closed his eyes and would not say another word to anyone. He was then admitted and died 5 days later after refusing to eat drink or take any meds. Not only was it hard on the patient, that was hard on all staff involved. Never and I mean NEVER will I do that to another human being who has made the conscious decision to die with dignity.

Here is a link of our DNR Policy, pay particular attention to this line.

AUTHORITY: Health and Safety Code Division 2.5, Section 1797.220 and 1798. Bartling V. Superior
Court, 163 Cal. App. 3d 186, 195 (1984), which ruled “The right of the competent adult patient to refuse medical
treatment is constitutionally guaranteed right which must not be abridged.”

http://www.norcalems.org/pnp-manual...ient_Care_Policies/302_Do_Not_Resuscitate.pdf

 

[JPINFV]

Corkey, would the family questioning a DNR make the validity of the DNR questionable in your mind?

From your link:

3. In unusual cases where the validity of the request is questioned, prehospital personnel should disregard the DNR request, institute BLS resuscitative measures. ALS providers should contact the base hospital immediately for direction.

 

[DrankTheKoolaid]

re

If the DNR is questionable to ME is how I read that. I don't really care if a family member questions it if it meets all the criteria and appears valid and has not been tampered with. (qualifying this last line) At the final moment of a patients life I have seen family members with every emotion imaginable in reaction to their loved ones death. Even with terminal end stage diseases have I witnessed various family members who have not been in the right place on the grief wheel have a very hard time with death, though this death was in no way unexpected and in some cases the patient lived weeks if not months longer then anticipated. I don't want to come off as cold, as I am not. But I will also be the first to step up and use the words dead and has died. This is not a time for sugar coating nor is it a time for using any other phrase that does not clearly mean this person is dead and is not coming back. And I am also the person who immediately switches roles and begins to contact clergy (after asking if they would like me to, as an atheist it took me a while to do this naturally) and other family members and assisting them in making final arrangements if they don't know how to go about it.

But in the end, if the family put up that much of a fight I would have BLS care initiated while attempting to contact base hospital if in an area where they either have a home phone or I have cell service. Which in my neck of the woods is certainly not a given. But if I have no way of making contact and DNR appears valid, that's the end of it.

 

[mycrofft]

Find out about the local laws about "unaccompanied deaths". Even if you respect the paper, you might be legally required to notify law enforcement or the coroner's office about a death which did not occur while under medical care.

(BTW, a coroner is the legal representative for the dead, and the coroner's office often includes the medical examiner, who does the autopsy. In the old days, often they were one in the same, but not very common nowadays. The coroner most often is busy doing things like finding next of kin to notify and take possession of the deceased's estate, making assure pets are sent to an animal shelter, securing the real property.

 

[DrankTheKoolaid]

re

Find out about the local laws about "unaccompanied deaths". Even if you respect the paper, you might be legally required to notify law enforcement or the coroner's office about a death which did not occur while under medical care.

(BTW, a coroner is the legal representative for the dead, and the coroner's office often includes the medical examiner, who does the autopsy. In the old days, often they were one in the same, but not very common nowadays. The coroner most often is busy doing things like finding next of kin to notify and take possession of the deceased's estate, making assure pets are sent to an animal shelter, securing the real property.

Excellent reminder there. Thankfully not an issue for us here as S.O. dispatch is also our dispatch and know what we are doing. And usually a Deputy is dispatched along with us to any report of a code or overdose

 

[triemal04]

In all three cases I would not begin resuscitation. If family is agitated I would move patient to the rig and leave for safer grounds while law enforcement was dispatched.

If you didn't plan on doing anything, why take the body with you? Liability? Personal safety? Just curious.

 

[DrankTheKoolaid]

re

Grab the body, move to truck, family assumes something is being done and they calm down. By that time LEO have typically arrived and then it's a null point anyway. But in reality I have only had to do this at SIDS deaths. Never in an adult or at a DNR.

I guess I could always just back myself and partner back into the rig, but in almost 20 years of doing this it has never come to that. Family has always realized after either myself or partners have talked with them that the patient is dead.. To be honest I have seen more drama while working in the ED at deaths, then I have in the field. This I really think relates back to most typical ED's dont allow a ton of family members into the room during the resus or lack there of, where in the field we are front and center stage in the living room bedroom or where ever. Studies have shown that it helps the grieving process to actually be present during the resuscitation or at the time of expiring. So I attribute the lack of drama in the field to this.

 

[Remeber343]

I'm my area if it is not a pending home death, Leo is dispatched for investigation. We are not able to move the body once we call it. Then after they do their investigation the corner picks them up.

 

[R99]

While the wishes of the family should be taken into consideration the family are not the patient so sorry at the end of the day it dont matter jack what they want if the patient has a clearly described directive then it is unethical for us not follow it

attempted resuscitation from cardiac arrest and out of hospital recognition of life extinct is just about the Intrusive and undignified thing you can have happen to you, why subject the patient and family to that if not completely necessary?

 

[johnrsemt]

Just remember that if you move the patient to the truck for safety/ clarification with the hospital, etc: and get orders to call the code or stop CPR and call the code: that in most locations your truck is now a potential crime scene until the coroner/Medical Examiner releases the body.

In my old service we had that happen twice, once they had the body for almost 7 hours in the truck. (That really screws up dispatch; because no matter how many pages and radio traffic you are out of service).

One crew was dispatched for mild difficulty breathing; when they got to the patient (BLS) they had basic Airway equipment: BVM, O2 tank, NRB, and NC. The patient was in full arrest; and rigored and with lividity present. They put the pt on the cot; called for ALS headed for the truck, starting CPR. (They weren't comfortable calling the pt at the scene, even though it is in the protocols there for BLS). ALS was 2 blocks away, got there as the pt got to the truck; called ED to confirm calling the pt (since CPR was started already). Then the ALS crew gave the pt back to the BLS crew; and called for the PD to come start their paperwork. The crew tried to take the body back to the ECF (they were still parked outside) DON had a cow over that, understandable.
The police was upset that they moved the body after declaration of death (going back into the ECF).
It took almost 7 hours to get it straightened out; and the crew was upset about going over then end of their shift, even with the OT.

 

[Spedz]

I agree with JP. In all 3 situation you described, it would be best to begin resuscitation, head for the truck, and let the hospital deal with the family.

I have always been told that if the family requests efforts be made, you go ahead and start CPR, despite the DNR. Also, if there are ever any doubts about the DNR or it's validity, start CPR. (This it the policy of my department, mind you.) Especially, if the scene is deteriorating and your safety is becoming an issue. Sometimes, the circumstances dictate that you have to make decisions your wouldn't ordinarily make.

Just a FYI (We had just covered this in class) DNR is no good for EMS (not in Indiana anyway) unless its a actual Out of Hospital DNR ( and unfort. not to many people even know of this so there are VERY VERY few out of hospital DNR) (according to my teacher there isnt even a lot of Doctors that know this form is even there):blink: (not sure why they have done this I think a DNR should be a DNR no matter what...anyway just my 2 cents).......WOW I really am learning something in class....................