# DNR Question



## Hockey (Feb 20, 2009)

If a patient has a valid DNR, and they are having inadequate breathing, does the DNR apply to lets say bagging them?  How bout not breathing?  Does DNR only apply to CPR/Shocking interventions?


I have a difficult partner that thinks she knows everything and was wondering what the correct answer is


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## Epi-do (Feb 20, 2009)

DNR = Do Not Resuscitate NOT Do Not *Treat*

If the patient is not in cardiac arrest, you must treat them exactly as you would any other patient that does not have a DNR.  The terminal cancer patient should be treated for the asthma attack they are having.  The terminal cancer is the reason for the DNR, not the asthma.  (Or whatever situation you want to come up with.  This was just the first example I thought of.)

This is a sore point with me.  I really don't understand how so many providers arrive at the conclusion that do not resuscitate = do not treat.  GRRRRR


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## Hockey (Feb 20, 2009)

Thank you because she was trying to state that was "Resuscitating" the patient and can get us in trouble if we did that.  

She is the absolute worst partner you can imagine.  Seriously.  You know what a Jr Coder is right?  She is the Chief Coder.

Had a PI the other day on the freeway and she said she can't get out of the truck because "scene isn't safe yet"

We were the first on.  Freeway was already jammed pack.  It was pretty safe.  So I jump out tell her to grab the backboard and collar and go to the rollover vehicle.  I look back before I got to the patient and told her to get out of the truck (nicely of course) and I hear her on the radio going "Dispatch scene not safe we need PD out here NOW!" 

Then she was flipping out because the coolant was leaking and told me we almost died after the call.  


Yes I went to supervisors about her but for some reason she still works here.  Yes I went online and verified she DOES have a license.  Scary...

She does know her stuff, she just can't apply it in real life....


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## Scout (Feb 20, 2009)

Just on that and lightly of topic,

as scence safety is subjective, what could or can be done to someone who is overcautious, surely it would be very hard to say with asolute certantly that the scene was safe and to have anything done about it.

to her the cooling fluid may have been petrol? or anything esle that presents a legitimate hazard.


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## JPINFV (Feb 20, 2009)

Epi-do said:


> DNR = Do Not Resuscitate NOT Do Not *Treat*
> 
> If the patient is not in cardiac arrest, you must treat them exactly as you would any other patient that does not have a DNR.  The terminal cancer patient should be treated for the asthma attack they are having.  The terminal cancer is the reason for the DNR, not the asthma.  (Or whatever situation you want to come up with.  This was just the first example I thought of.)
> 
> This is a sore point with me.  I really don't understand how so many providers arrive at the conclusion that do not resuscitate = do not treat.  GRRRRR



Ahh, but there's the issue. In general DNR orders include prohibition against mechanical ventilation, advanced airways, and a whole slew of other interventions. Sure, if a patients is having an asthma attack go for the albuterol, but once the patient goes into respiratory and/or cardiac arrest, regardless of etiology, then the it's game over.


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## Epi-do (Feb 20, 2009)

JPINFV said:


> Ahh, but there's the issue. In general DNR orders include prohibition against mechanical ventilation, advanced airways, and a whole slew of other interventions. Sure, if a patients is having an asthma attack go for the albuterol, but once the patient goes into respiratory and/or cardiac arrest, regardless of etiology, then the it's game over.




Yes, you are correct.  I should have qualified my answer with "in my area."  Here, while in the hospital you may choose from an entire smorgasboard of options for your DNR.  However, in the field, for EMS it is all or nothing.  We are not allowed to only do compressions, or only push meds, or only *insert any other option here.*

If, as the OP asked, the patient is having inadequate respirations, but they still have some respiratory effort, we are obligated to bag them and provide appropriate airway management.  Likewise, if they are in respiratory arrest, but not cardiac, we are obligated to do what we can.  If, for instance, the respiratory arrest is due to an obstructed airway, we are expected to do what we can to open the airway and ventilate.  If the patient continues to deteriorate, once their heart stops and they are in cardiac arrest, only then are we able to cease efforts.


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## JPINFV (Feb 20, 2009)

Epi-do said:


> Likewise, if they are in respiratory arrest, but not cardiac, we are obligated to do what we can.  If, for instance, the respiratory arrest is due to an obstructed airway, we are expected to do what we can to open the airway and ventilate.  If the patient continues to deteriorate, once their heart stops and they are in cardiac arrest, only then are we able to cease efforts.


I'm curious then because that's not what the Indiana prehospital DNR form states.


> I direct that, if I experience cardiac or* pulmonary failure* i a location other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that I be permitted to die naturally.


http://www.in.gov/icpr/webfile/formsdiv/49559.pdf

In terms of picking and choosing, I think you missed my point. Where I'm currently working a DNR is also an all or nothing order. At the same time it specifically prohibits certain interventions such as intubation, mechanical ventilation, and the like.


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## BEorP (Feb 20, 2009)

In Ontario, we would not bag someone who has a valid DNR. See page 3 for a sample of our DNR forms. They specify right on them what interventions are considered to be "resuscitation." 

http://www.ambulance-transition.com/pdf_documents/training_bulletin_108_v1_dnr_standard.pdf


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## Epi-do (Feb 20, 2009)

JPINFV said:


> I'm curious then because that's not what the Indiana prehospital DNR form states.



It's per our protocol:



			
				Indpls Metro Region EMS Protocols 2009 said:
			
		

> DETERMINING THE NEED FOR RESUSCITATION
> 
> ...
> 
> ...



No where else in our protocols are DNRs addressed.  Granted, we can always call the hospital and talk to the doc if we have a respiratory arrest patient that has a DNR and family is adament we do not do anything.  Then it comes down to how well you can paint a picture for the doc on the other end of the radio.  

If you get a baby (as in "new", not pediatric/neonate) doc on the other end it is a complete crap shoot whether or not they would let you not do anything.  Most of them are going to play it safe and have you do what you can.  If you get one of the docs that have been around for a while and give a good report you are most likely going to be granted your request to honor the DNR.


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## BossyCow (Feb 20, 2009)

This is why our state went from a DNR to a POLST. Physician's Orders on Life Sustaining Treatment. This document outlines what is an what is not acceptable treatment in specific situations.


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## lightsandsirens5 (Feb 20, 2009)

Here is Washingtons POLST form. LIke BossyCow said, it has more detailed info ref. what to do and not to do.

http://www.wsma.org/files/Downloads/PatientResources/polst_form.pdf

It can get a little confusing though. I went on a code once and the family told us that the pt had a DNR. Well, my partner saw the POLST on the back of the door and the pt had the CPR/Attempt Resuscitation box and the Full Treatment box both checked. :wacko:


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## MSDeltaFlt (Feb 20, 2009)

Hockey9019 said:


> If a patient has a valid DNR, and they are having inadequate breathing, does the DNR apply to lets say bagging them?  How bout not breathing?  Does DNR only apply to CPR/Shocking interventions?
> 
> 
> I have a difficult partner that thinks she knows everything and was wondering what the correct answer is





BossyCow said:


> This is why our state went from a DNR to a POLST. Physician's Orders on Life Sustaining Treatment. This document outlines what is an what is not acceptable treatment in specific situations.



With this country being as litigation happy as it is, Bossy's protocol seems a very safe way to go, unfortunately.  DNR's were meant to let those who are dying to go ahead and die in peace.  So check your state and local guidelines first.

Around here?  If they stop breathing, we won't bag 'em.  If they don't have a blood pressure, we won't give them one (Dopamine, pacing, etc).  If they lose a pulse, we won't generate one.  So long as they have a valid DNR copy to give us.  Translation: if they're dying, we let them die.  Around here resuscitation is considered life support.  The forementioned are considered life support. 

However, if they're short of breath, having chest pain, nausea/vomiting, diarrhea, or anything else, we treat it.  

Get the point?


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## Epi-do (Feb 20, 2009)

lightsandsirens5 said:


> Here is Washingtons POLST form. LIke BossyCow said, it has more detailed info ref. what to do and not to do.
> 
> http://www.wsma.org/files/Downloads/PatientResources/polst_form.pdf
> 
> It can get a little confusing though. I went on a code once and the family told us that the pt had a DNR. Well, my partner saw the POLST on the back of the door and the pt had the CPR/Attempt Resuscitation box and the Full Treatment box both checked. :wacko:



That definately spells things out without as much grey area as a DNR, especially when the family is telling you contradictory things from one member to the other, or compared to the DNR.  I have also come across families that don't understand a living will is different than a DNR and we cannot honor a living will. In certain circumstances though, I have heard of docs granting online orders to EMS onscene regarding details specified in a living will.


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## lightsandsirens5 (Feb 20, 2009)

Epi-do said:


> That definately spells things out without as much grey area as a DNR, especially when the family is telling you contradictory things from one member to the other, or compared to the DNR.  I have also come across families that don't understand a living will is different than a DNR and we cannot honor a living will. In certain circumstances though, I have heard of docs granting online orders to EMS onscene regarding details specified in a living will.



Yep. Leading the way in EMS here in the Peoples Republic of Washington.

(Just kidding of course.)


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## ffemt8978 (Feb 20, 2009)

Epi-do said:


> That definately spells things out without as much grey area as a DNR, especially when the family is telling you contradictory things from one member to the other, or compared to the DNR.  I have also come across families that don't understand a living will is different than a DNR and we cannot honor a living will. In certain circumstances though, I have heard of docs granting online orders to EMS onscene regarding details specified in a living will.



And family on scene can override a POLST...which is why we always call Med Control in situations like that.  Let the guy with all of the education hang it out there for the lawyers to take shots at.


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## medic417 (Feb 20, 2009)

ffemt8978 said:


> And family on scene can override a POLST...which is why we always call Med Control in situations like that.  Let the guy with all of the education hang it out there for the lawyers to take shots at.




Med control is not an option for some of us, so we have to decide.


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## ffemt8978 (Feb 20, 2009)

medic417 said:


> Med control is not an option for some of us, so we have to decide.



Huh?  What do you mean med control is not an option?


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## JPINFV (Feb 20, 2009)

Not every place has online medical control.


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## ffemt8978 (Feb 20, 2009)

JPINFV said:


> Not every place has online medical control.



Even so, can't you call the receiving facility and speak to the ER doc?


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## JPINFV (Feb 20, 2009)

Nope. When I worked in So Cal we sent our entry note to dispatch (age, sex, PMD, CC, anything direly important [normally nothing]) and dispatch called the hospital. It wasn't until I started working in MA that I actually called the hospital direct for anything.


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## medic417 (Feb 20, 2009)

ffemt8978 said:


> Even so, can't you call the receiving facility and speak to the ER doc?



You have to have contact to talk to them.  My area you can not hit the hospital by radio and cell phones don't work in many areas.  It is just me and my partner.


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## ffemt8978 (Feb 20, 2009)

medic417 said:


> You have to have contact to talk to them.  My area you can not hit the hospital by radio and cell phones don't work in many areas.  It is just me and my partner.



You're not anywhere near me, are you?  Around here, smoke signals seem to be the most reliable form of communication.


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## Pudge40 (Mar 1, 2009)

In Pennsylvania the BLS protocols states that if they go into respritory arrest we are not allowed to bag them it does not state about if they are in distress though. And the only DNR that we can accept is an out of hospital DNR. If they have a normal DNR we must start CPR and contact medical comand to get the order to stop.


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## MJD1521 (Mar 6, 2009)

Hockey9019 said:


> If a patient has a valid DNR, and they are having inadequate breathing, does the DNR apply to lets say bagging them?  How bout not breathing?  Does DNR only apply to CPR/Shocking interventions?
> 
> 
> I have a difficult partner that thinks she knows everything and was wondering what the correct answer is



Most DNR's in my experience will have a list of treatment options that the patient would not like should they go into cardiac or respiratory arrest.  Up until you determine that they are in fact in cardiac or respiratory arrest, treat as you would any other patient.

(This is my understanding of it)


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## frdude1000 (Mar 8, 2009)

A DNR (Do Not Resuscitate) order is a form of an advance directive.  An advance directive "tells medical responders and doctors what kind of care you would like to have if you become unable to make medical decisions".  A DNR specifically states to do not do cpr or try to restart the heart.  Also, it also states to not try to restore breathing because that falls under "resuscitate".


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## Juxel (Mar 16, 2009)

I had a difficult DNR case recently.  Pt has terminal lung cancer and lives at a nursing home.  Staff called pt's wife to inform her of pt's deteriorating condition and wife asked for him to be brought to the hospital.  911 is called.

We arrive to find pt in severe respiratory distress (RR-70ish, O2 sats in the 60s, only response you can get from the pt is eye opening to voice).  Staff cannot find his DNR order, but states he has one.  We are ~15 minutes from the hospital Code 3.

I bagged him for the trip in.  No IV, no airway devices, no meds, just a little assistance moving some air.  Enroute to hospital I contacted online med control who pulled his chart up and saw a copy of his valid DNR.  Wife arrived at the ED about the same time we did with a son.  They were able to say goodbye before the pt died 7 minutes later.

While I was writing my chart I was debating whether or not I should have bagged him.  Before I finished writing the chart his wife and son came up to me and thanked me for doing everything I did and giving them the chance to say goodbye one last time.  I knew then I did the right thing, at least for this patient.


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## Katie Elaine (Mar 16, 2009)

I'm a bit confused. I'm a new B-tech, and during my class I remember we had quite a debate about DNRs and what they cover and what they don't. Doesn't the DNR have a list of things that you can and cannot do? From what my instructor talked to us about, I gather that the patient says what interventions they want and are acceptable, and where to stop resucitation.


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## JPINFV (Mar 16, 2009)

It's really a location by location issue. Some due have more information in terms of what interventions the patient wants and doesn't want. Others just ban life support measures such as mechanical ventilation, CPR, defibrillation, cardioversion, and the like.


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## medicp94dao (Apr 10, 2009)

Epi-do said:


> DNR = Do Not Resuscitate NOT Do Not *Treat* QUOTE]
> 
> i agree. if the are dead leave them that way. if they have a pulse, and are breathing then you work them. To quote my medical director " a DNR can be revoked at anytime this includes death" a pt family member of at least 18 years of age and is a close family member i.e;parents, children, siblings, and grandchildren can revoke the DNR at any time and it only takes one to do so. Even if you are holding the VALID DNR in your hand and one of them say to save that pt, you have to do as they wish...... if in doubt always consult medical direction...


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## TransportJockey (Apr 10, 2009)

medicp94dao said:


> Epi-do said:
> 
> 
> > DNR = Do Not Resuscitate NOT Do Not *Treat* QUOTE]
> ...


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## EMTinNEPA (Apr 10, 2009)

I was under the impression that only the patient's medical power of attorney could override a DNR.


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## Ridryder911 (Apr 10, 2009)

EMTinNEPA said:


> I was under the impression that only the patient's medical power of attorney could override a DNR.



Actually, most states describe that the patient or any immediate family member can interupt and cease DNR orders. 

R/r 911


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## reaper (Apr 10, 2009)

Yes, in most states immediate family can override a DNR. It is usually for selfish reasons and should not be aloud, but it is valid.


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## JPINFV (Apr 10, 2009)

^
What if the patient said "Save me," just before s/he coded? Resuscitation and life support can always be stopped/withdrawn. Once you decide to terminate a resuscitation/life support, you can't go back.


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## TransportJockey (Apr 10, 2009)

JPINFV said:


> ^
> What if the patient said "Save me," just before s/he coded? Resuscitation and life support can always be stopped/withdrawn. Once you decide to terminate a resuscitation/life support, you can't go back.



The patient, the one who originally filed the paperwork,has every right to withdraw that document


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## JPINFV (Apr 10, 2009)

^
Yes, and that's my point. What if the patient withdrew the DNR just prior to going into cardiac arrest. EMS gets called, shows up, finds DNR, and family asks EMS to resuscitate the patient. Hence the reason why family should be able to withdraw the DNR as well as the patient.


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## Moxiy (Apr 19, 2009)

If it means anything, I just finished my EMT class and my professor on the last day of class confirmed that BVM is indeed a form of Resuscitation and should not be applied during a DNR.


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## TransportJockey (Apr 19, 2009)

JPINFV said:


> ^
> Yes, and that's my point. What if the patient withdrew the DNR just prior to going into cardiac arrest. EMS gets called, shows up, finds DNR, and family asks EMS to resuscitate the patient. Hence the reason why family should be able to withdraw the DNR as well as the patient.



If the pt has been of sound mind until the point he dies, why should the family have a say in it? If the pt doesn't want to be resuscitated, then do not do it. It seems like the family will always ask you to invalidate the DNR, at least around here it does.


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## Ridryder911 (Apr 19, 2009)

jtpaintball70 said:


> If the pt has been of sound mind until the point he dies, why should the family have a say in it? If the pt doesn't want to be resuscitated, then do not do it. It seems like the family will always ask you to invalidate the DNR, at least around here it does.



Because most states will honor the "loved ones request". This is a dangerous area and most services have a legal protocol in case it happens. Ours it to proceed with resuscitation as it is clear within my state that ..."the patient, immediate family members, patients proxy may remove DNR status at anytime"....

I have read of court cases where EMS did not honor immediate family member request and was held responsible. So, again I would consult with your legal department for clarification. 

R/r 911


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## VentMedic (Apr 19, 2009)

Moxiy said:


> If it means anything, I just finished my EMT class and my professor on the last day of class confirmed that BVM is indeed a form of Resuscitation and should not be applied during a DNR.


 
In some states that is not always true. A DNI (Do Not Intubate) order may also need to accompany the DNR. If it is impending respiratory failure from PNA or CHF, we may use Non Invasive Ventilation or even intubate for conditions that are deemed to be reversible.


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