DNR/Advanced Directivies.

[Spedz]

Heres a pic of one was gonna put it on my other post however I didn't realize I only had 15 minutes to edit my post (ok whatever)......

 

[JPINFV]

Does Indiana have statewide protocols or a statewide DNR policy posted online? The reason I ask is because I can't find anything on Indiana EMS's website, but did find the following document dated from 2010:

"B. Do Not Resuscitate (DNR) orders:
1. If health care personnel or family members are present at the scene of a patient in cardiopulmonary arrest and request that resuscitative measures be withheld, request to see a DNR order that has been signed by the attending physician. If presented, resuscitative efforts should not be initiated or may be terminated.

2. In the event the family or health care personnel cannot produce this document immediately, begin resuscitative efforts in accordance with the appropriate protocol and transport.

3. If there is any question regarding the validity of the written order, resuscitative measures should be initiated. Contact the receiving facility for further orders.

These guidelines do not apply to a Living Will."

pg. 12
http://www.decaturfire.org/2010EMSPROTCL.pdf

Nothing specific is said about requiring a specific DNR format. Point 3 would be used in the OP scenarios to begin resuscitation pending base hospital contact.

 

[Spedz]

Does Indiana have statewide protocols or a statewide DNR policy posted online? The reason I ask is because I can't find anything on Indiana EMS's website, but did find the following document dated from 2010:

"B. Do Not Resuscitate (DNR) orders:
1. If health care personnel or family members are present at the scene of a patient in cardiopulmonary arrest and request that resuscitative measures be withheld, request to see a DNR order that has been signed by the attending physician. If presented, resuscitative efforts should not be initiated or may be terminated.

2. In the event the family or health care personnel cannot produce this document immediately, begin resuscitative efforts in accordance with the appropriate protocol and transport.

3. If there is any question regarding the validity of the written order, resuscitative measures should be initiated. Contact the receiving facility for further orders.

These guidelines do not apply to a Living Will."

pg. 12
http://www.decaturfire.org/2010EMSPROTCL.pdf

Nothing specific is said about requiring a specific DNR format. Point 3 would be used in the OP scenarios to begin resuscitation pending base hospital contact.

Is this what your asking for? If not I will try to find more info and again just what I was taught in class lol





http://www.in.gov/legislative/ic/2010/title16/ar36/ch5.html

 

[JPINFV]

I came across that too, and it looks like it falls short of mandating it in favor of authorizing it. Here's my two issues with requirng a specific form.

1. If you're doing a discharge or transfer from an acute care hospital, since they do not have to follow an OOH DNR form, can you accept their in-house DNR form/order?

2. Same question as 1, but from a health care facility like a nursing facility?

To me, it makes no sense to limit the acceptable options in those situations.

 

[Spedz]

According to class NO YOU MAY NOT accept any DNR unless its the out of hospital one no matter what.

 

[jjesusfreak01]

I'll use any excuse to throw a NC DNR out the window, as I have absolutely no idea whether it represents the will of the patient or the family. It only needs the patient's name and a Dr's signature on it. If they would change the stupid form to require signatures from the patient or POA, I would have no problem honoring it against the families wishes (assuming it was legal for me to do so).

I just can't in good conscience honor a form that a competent patient may have never seen or been asked about before arresting.

 

[JPINFV]

What physician is his or her right mind would sign a DNR without discussing it with a competent patient, or an incompetent patient's POA?

Note: POA doesn't necessarily require a legal document, as most, if not all, parts of the US are going to have some way of allowing family members to make treatment choices in the event of an unexpected catastrophic medical disorder or injury that removes the patient's ability to make a choice, such as someone who suddenly finds their way to being on a vent in the ICU.

 

[Melclin]

I have a few different scenarios for this:

1) You arrive, patient has signed DNR orders, but the family there is frantically screaming and asking you to do everything you can for the patient. It was an unwittnessed arrest, patient was just found. You tell the family you wish to respect the deceased wishes, and you deny any resuscitation attempts. The family become agitated and start to get aggressive.

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.

This seems like an issue of personal safety rather than medical ethics.

1. DNR, agitated potentially violent family, unwitnessed arrest: Explain better if you can, retreat if you can. If not start resus. My life and well being is worth more than their end of life wishes. They're dead anyway and I don't feel like joining them.

1a. DNR, agitated potentially violent family, witnessed arrest: What does it being witnessed have to do with it? See step one.

2. Depends on whether or not he's past the point of resus. If he's past resus, don't (if they get violent, see step one). If he's viable, I'd start. I'm acting, in good faith, on what I believe the pt's wishes are as conveyed to me via the family. That is enough for me.

 

[jjesusfreak01]

What physician is his or her right mind would sign a DNR without discussing it with a competent patient, or an incompetent patient's POA?

Note: POA doesn't necessarily require a legal document, as most, if not all, parts of the US are going to have some way of allowing family members to make treatment choices in the event of an unexpected catastrophic medical disorder or injury that removes the patient's ability to make a choice, such as someone who suddenly finds their way to being on a vent in the ICU.

Well, we have the nursing home docs, and then we have the hospitalists who seem to sign a DOR for just about every geriatric patient discharged from the hospital following a debilitating injury. It may be that most of these DORs have been discussed with the patients and families, but I just don't know, because there's no evidence.

We have a secondary form in NC called a MOST form that requires the patient (or legal representative) signature in addition to a high level provider (MD/DO/PA/NP), and it must be reaffirmed (and resigned) by the patient and provider at any time there is a major change in facility or major change in health status. This is what the DOR should be.