# DNR Prescription Pad?



## RWC130 (Dec 31, 2009)

New York State:

I responded on a call yesterday for a 72 y/o male with Chest Pains.
The pt. was treated and transported and is OK.

What I did find very interesting was when I asked his wife about his
medical history, meds, etc.... she stated "he has a DNR" and handed
me a doctor prescription pad that had the patient name, dob, and
written "DNR No Advanced Treatment"

I am glad he didn't go into Cardiac Arrest. :wacko:

This was interesting.

What would YOU so on this one?


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## apumic (Dec 31, 2009)

Did it meet all the legal requirements for your state for a DNR? (e.g., signatures by both physician and pt, etc.)
If so, it's a legal DNR order, right? Since that seems like a strange way of doing a DNR, I'd probably want to check with medical direction before refusing care.
If the DNR on an Rx pad didn't meet all the legal req'ts for a DNR in your state, I think it'd be a moot point as the DNR would not be legally binding (i.e., you have to provide care as the DNR would be invalid). In my understanding, a DNR is essentially the juxtaposition of two principles of medical law -- duty to provide the standard of care and consent of the pt. If the pt is unconscious or has an altered LOC then consent is implied. A valid DNR, properly written and signed by both physician and pt would indicate a withholding of consent. Consent always takes precedence over duty (as to provide care without consent would be battery); however, if consent is given, duty to act becomes law. So in the current scenario, you appear to have someone who, while having had a DNR order signed by a physician, has not authorized (signed) the order him/herself. In my understanding, a physician's signature would essentially act as a witness to the pt (and a healthcare provider per law in verifying the order) but s/he would not have the authority to authorize the withholding of care unilaterally without the pt's agreement.


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## JPINFV (Dec 31, 2009)

Depends on where I am. In Massachusetts, the only thing valid is an EMS "DNR/Comfort Care verification form." 

In California, however, it's up to each county. First off, she say's that she's a DNR. While the technical language is "immediate family members" or "health care agent," I think it's a safe bet to assume that the patient would have the same power over her life/treatment provided that she is of sound mind. As such, I would write a short statement at the start of the narritive stating that the patient decliens resuscitation and have the patient sign immediately below the statement. The DNR pad order would be a valid order as well if the patient was in a licensed health care facility.

Orange County, CA DNR protocol. It is important to note that EMT-Bs do not have access to online medical control, so any disagreement among family members or concern over the validity of a DNR  requires a call for paramedics (I'd argue that a 2 person EMT-B crew can not effectively transport a patient in cardiac arrest, hence distance to ER is irrelevant unless you're physically right outside the door).

Orange County, CA EMS DNR protocol. http://ochealthinfo.com/docs/medical/ems/P&P/330.51.pdf

As a side note, this is why I recommend that everyone carries a copy of their local DNR policy in their clipboard. It's not something that get's drug out often, but there should be no room for question when needed. This is, unlike most of EMS, always a matter of life and death.


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## Shishkabob (Dec 31, 2009)

Depends on your local laws, and quite frankly this is something that you should already know and not have any question about.


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## reaper (Dec 31, 2009)

As Linus said, You should know the state laws, that you are in.

If there is any doubt, you work them and let the MD sort it out.


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## nomofica (Jan 1, 2010)

Gonna beat a dead horse here: if it doesn't mean the legal requirements then ignore it and do your job as if you had never seen the Rx pad. If you're sill iffy on working it, well... there's a reason why we have medical direction.


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## LondonMedic (Jan 2, 2010)

apumic said:


> Did it meet all the legal requirements for your state for a DNR? (e.g., signatures by both physician and pt, etc.)


Do you need the pt's signature? Is that a US or state thing?


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## RWC130 (Jan 3, 2010)

Linuss and Reaper,

I only posted this for a "discussion" because I found this to be interesting call
and thought others on the board might enjoy the scenario.

In my 17 years as an EMT I would hope I know what I am doing. lol

Medical Orders for Life-Sustaining Treatment

http://www.compassionandsupport.org... 2008 Revision.FINAL_.101308_.kr_.SAMPLE_.pdf


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## Sasha (Jan 3, 2010)

LondonMedic said:


> Do you need the pt's signature? Is that a US or state thing?



You need the patient or POA/Proxy. A physician can't just say DNR without patient or family or appointed legal guardian/power of attorney giving the go ahead.


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## JPINFV (Jan 3, 2010)

Depends on local protocols. I can accept a written order in the patient's chart at a licensed health care facility. The patient and/or family does not cosign orders in a patient's chart. However, if it comes out that a proxy or the patient did not agree to the order, the legal issues fall to the physician writing the order and not the EMS crew honoring the physician order.



> C. EMS personnel shall honor a DNR request when it can be reasonably established that the patient is subject to the DNR request, and
> ...
> 2. EMS personnel have personally seen the DNR order in the patient's medical record in a health care delivery facility.


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## Aidey (Jan 3, 2010)

"No advanced treatment" leaves a lot up for interpretation. 

In my area that would not have met the requirements, as the patient or a legal proxy has to also sign it. It also has to be dated, and the MDs name has to be both signed and legibly written on the form.


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## rescue99 (Jan 3, 2010)

I cannot speak for every location but, I can speak for here. For many years, every 6 months or so we had a new DNR prescription hanging on our refrigerator. The pediatrician would write a new one once, maybe twice a year, just like any other prescription. It does not require a signature other than the Physician's. A prescription pad is a legal document in itself however, it is short term. 

I've also transported dozens of hospice patients or DNR folks with the exact same type of prescription. If the hospice or legal DNR document isn't with the patient and there's some reason to believe the person could expire enroute, I've asked for and gotten a script.


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## LondonMedic (Jan 3, 2010)

Sasha said:


> You need the patient or POA/Proxy. A physician can't just say DNR without patient or family or appointed legal guardian/power of attorney giving the go ahead.


That sounds like bad times. <_<


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## MedicSqrl (Jan 6, 2010)

FL has a community DNR on yellow paper that stays with the pt.

Dr and Pt/POA need to sign along with Dr lic# and info


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## redcrossemt (Jan 8, 2010)

Michigan has certain requirements outlined in the DNR act (194, like both the patient's (or their advocate's) signature and the physician's signature, and wording "substantially" following their recommended form.

This could be met on a prescription pad, but I've never seen it all written out...


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## Jeffrey_169 (Jan 9, 2010)

I have never seen a DNR on a prescription before. This is news to me. My wife was a CNA for 2 years and she has never heard of it either. 

A simular situation happaned to me a fews years back, and it was a case where the DNR could not be produced. We iniated advanced care and low and behold there was a DNR. We were told we did right because the proper documentation could not be produced. It was then I realized, if in doubt do not with hold care; immediately contact med. control and initiate whatever care is necessary for the situation at hand, in this case supportive care.


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