DNR's, DPOA's, LW's, etc.

[EMT Dave]

At my current location, a retirement community, a fellow EMT ran an emergency call that involved CPR. Immediately, a family member stated that the patient had a valid DNR. (This family was retired from the medical profession). The family member asked the EMT not to resuscitate, due to the patient having a DNR. The EMT stated that until he produced the original form, then CPR was going to be initiated, which it was. The family member persistently asked the EMT not to resuscitate the patient, but failed to produce the original DNR order. Instead, giving a DPOA/Living Will. The EMT stated that he could not accept these documents and continued with CPR.

On page 3 of the document that was given to the EMT, it stated “all life-sustaining procedures be withheld or withdrawn, including CPR”. After the EMT stated that he could not recognize this document, our medical director was contacted. In the report it states, “we explained the situation and the document we had, and with the direction of Dr. ___, we honored the document and CPR was stopped”. An outside agency arrived, and re-indicated CPR, due to them not recognizing the DPOA/Living Will. As the first EMT on scene did not recognize this either.

Eventually, contact was made with the patients “personal physician” and life saving measures were ceased. Per the report, our medical director was not the primary care physician. Am I correct in stating that he should NOT have advised the EMT to stop CPR? It’s kind of a gray area, as the EMT knew he couldn’t recognize the DPOA document, but followed the orders of our medical direction (who isn’t the primary physician of the patient) to cease life saving measures. Did our medical director break some code of ethics by honoring the family’s wishes without proper documentation being presented ? I say yes, and now we’re in between a rock and a hard place…:huh:

 

[NomadicMedic]

It's a gray area, for sure. However, if the family is adamant and they have a signed document, I place the onus on med control. Not being there, its hard to make the call, but most likely would not have started that resuscitation.

We occasionally find DRN orders scribbled on a prescription pad. I'm certainly not afraid to begin a resuscitation, but the EMS professional has to use common sense and judgement.

Ive also found this to be more of a first responder/BLS level issue. As a medic, I have no problem stopping a code that EMTs have initiated. Sadly, it happens more frequently than it should.

 

[JPINFV]

This is one of the few areas where you have to know and follow local policy strictly. The retirment community EMT needs to follow the community/facility's policies regarding honoring or not honoring DNRs. The EMS crew needs to follow the EMS system's policy regarding DNRs. Where I worked for most of my time, the verbal request from an immediate family member (by statute these are the patient's adult children, adult siblings, parents, spouse, or domestic partner). Similarly, a power of attorney can communicate a DNR. As such, your system's policies may vary, and should be looked up and followed regardless of what is said here.

/Cue, "OMG, a verbal DNR, you must be joking" post.

 

[NomadicMedic]

Very true. JP should be quoted for truth! Getting information and advice on a legal issue as sticky as this from an Internet forum is akin to asking that weird uncle you have to babysit. Just not a good idea.

Medical directors and/or supervisors should be able to provide the final ruling on this issue. Remember not every system is created equal. What works for me, may not work for you.

 

[EMT Dave]

I wasn't asking or looking for legal advise and I know my protocols. We just got into a discussion about whether our MD should have stopped CPR, knowing the family didn't produce the proper documentation.

Being at a retirement community is different than running calls for normal civilians. You get to know these patients on a different level. Which is the logical explanation we came up with. The EMT did everything he was suppose to, but technically he (dr) probably shouldn't have done it. We're not expecting rprocussions from the call either, just wanted some other opinions in the matter.

 

[EMT Dave]

Our policies don't differ from an outside agency either.

 

[hippocratical]

So if it turns out that the Medical Director was wrong to call off the CPR, who gets in trouble?

Does the EMT get in trouble even though they were following orders?

 

[EMT Dave]

I don't think he (EMT) would get in trouble. He followed medical direction's advice.

 

[JPINFV]

The 2 questions that needs to be answered are:

1. Was the physician authorized to give that order (i.e. is he a medical control physician? If not, what limitations are placed on private physicians issuing medical orders? In the system I'm most familiar with, the patient's physician can write a DNR order on the PCR (and he signs the PCR) that the crews can follow, however this cannot be a phone order)?

2. Is the physician empowered to give that order? Just because the physician gave an order doesn't make it manifestly valid. Wasn't it about a decade ago where there was the 2 medics in, if I remember correctly, New Jersey, who lost their paramedic license after doing a post-mortum c-section with a medical control order?

 

[EMT Dave]

1- That's where it gets tricky. He does have the right to request, however I'm unsure if he was the Dr. that signed/ordered the DNR. I want to say no, because in the report it says the outside agency contacted her personal physician, who directed them to stop.....again. I think our MD overstepped, but had the best interest in mind.

2- I'm not familiar with, but I can say I would tell that MD I don't feel comfortable performing that task. That's an extreme case where better judgement could have been used, I mean EMT's aren't surgeons....

 

[Handsome Robb]

So why is it wrong to honor the final wishes of a person. I say the med director called it right.

Any lawyer is going to have a real hard time proving the MD was wrong calling for resuscitation to be stopped unless state law specifically says DPOA/Living Wills are invalid/not accepted.

And it was two Paramedics in NJ not EMTs. They lost their livelihood, the MD had to go through a few hours of remedial Medical Control training....

 

[EMT Dave]

State law says EMS cannot honor them, because there's no protocol in place to guide the workers. Hence, "a living will is not considered a valid document.

 

[Handsome Robb]

State law says EMS cannot honor them, because there's no protocol in place to guide the workers.

Ok, so EMS can't but your Med Director is a physician, not EMS. He doesn't have to follow protocols like EMS personnel do. You are working as an extension of his medical license.

I don't think he overstepped. Just my opinion though, don't shoot me.

Side note, not speaking about you at all but how much guidance from a protocol does someone need to read a document that is signed by a MD that sucks "No life saving measures including CPR"?

 

[EMT Dave]

LoL. I'd never do such a thing. Your explanation makes sense though. I failed to look at it from ALL aspects. Thanks for the input.

 

[JPINFV]

So why is it wrong to honor the final wishes of a person. I say the med director called it right.

I agree, but that's not how the system is set up and why I really like how liberal Orange County, CA's DNR protocol is.

Any lawyer is going to have a real hard time proving the MD was wrong calling for resuscitation to be stopped unless state law specifically says DPOA/Living Wills are invalid/not accepted.

I bet I could find one easily if the EMS providers operated in a manner contrary to the rules and laws set in place.

And it was two Paramedics in NJ not EMTs. They lost their livelihood, the MD had to go through a few hours of remedial Medical Control training....

The fact remains that "Befehl ist Befehl" (orders are orders) didn't protect them, and the fact that "Befehl ist Befehl" isn't a defense isn't just limited to paramedics.

 

[PotatoMedic]

Here is the guidelines per king county:

EMTs have the responsibility to determine a
patient’s resuscitation wishes, and honor them
if possible.
Resuscitation efforts may be withheld or
stopped in ANY of the following:

• Injuries incompatible with life
• Lividity, rigor mortis
• A Do Not Attempt Resuscitation (DNAR)
  directive. This directive may be in the
  POLST (Physician Orders For Life-
  Sustaining Treatment) format. This is based
  on patient’s wishes.
• “Compelling reasons” to withhold
  resuscitation can be invoked when written
  information is not available, yet the situation
  suggests that the resuscitation effort will be
  futile, inappropriate, and inhumane. A
  resuscitation effort may be withheld when
  the following two conditions are BOTH met:

• End stage of a terminal illness
• Family indicates that the patient would not
  wish to have a resuscitation effort
  If a resuscitation effort has been initiated and
  the EMT is provided with a DNAR directive or
  compelling reasons that such an effort should
  be withheld, the resuscitation should be
  stopped.

If I was presented with a living will that said DNR and the guy was not terminal I would contact the medics and go with what they say. And yes I know they may need to call the doc. But I would have initiated CPR knowing that I can stop at anytime if told to.

 

[NomadicMedic]

That's a nice thing about Washington state, they have the green POLST form that is statewide. That's really the only honorable DNR form that Washington let's EMTs make the decision with. I wish that all states had a standardized form… Like I said, here, sometimes we will have a DNR scribbled on a prescription pad.

 

[JPINFV]

That's a nice thing about Washington state, they have the green POLST form that is statewide. That's really the only honorable DNR form that Washington let's EMTs make the decision with. I wish that all states had a standardized form… Like I said, here, sometimes we will have a DNR scribbled on a prescription pad.

So... Washington State thinks that their EMS providers are too stupid or ignorant to deal with DNR orders unless it's on a special piece of paper? How professional.

 

[Aidey]

From reading the King County protocol it sounds like it doesn't have to be a POLST form, but it may be presented in that form.

As everyone else has said, you have to follow local protocol.

In my personal opinion everyone involved except the doc was wrong. Immediate family on scene, clear orders written in a legal document, and on-line orders to stop CPR and it STILL happened. If I ever contacted med control for orders to stop and another agency showed up and continued the police would be called so fast their heads would spin.

 

[NomadicMedic]

So... Washington State thinks that their EMS providers are too stupid or ignorant to deal with DNR orders unless it's on a special piece of paper? How professional.

Not only that, but the paper has to be posted on the bedroom door, or on the fridge of the patient who has the POLST. Also, the original is supposed to follow the patient from place to place. Say what you want, but one standardized form certainly does make it easier to know what to look for. The nursing homes and hospice care providers all know exactly what you mean when you say, "I need the green form". There's never any question. Now of course, there are some instances where a POLST form isn't used, such as a patient in a skilled nursing facility. The DNR orders would be written in the chart. However, for homebound and assisted living patients, they need to have a POLST.