# DNR discussion



## trauma1534 (Dec 4, 2006)

I had an incident this weekend when I worked that raises discussion.  I am currious as to how you guys would handle this from varios areas, and levels.  

You have an unresponsive patient who suffered a fall about 7 hours prior to this call.  The patient has CSF from the ear, all signs of a classic head bleed.  She is 88 years old.  Nursing home patient with a DNR for a terminal illness.  

Would you intubate?

Woud you BVM?

Would you use Oral Airway?

Would you start an IV?

Due to it being an obvious head injury, erasing the fact that she is a nursing home patient, would you consider air lifting this patient?  

I am curious.  Now let me add... one of the guidlines for airlifting a patient is head injury.   It didn't say age, or where they reside, or even if they have a DNR.  

I don't want this topic to get disrupted by what patients we can fly, I want to focus on everyone's take on treatment for a traumatic injury in a DNR patient.


----------



## Guardian (Dec 4, 2006)

I'd advise you to look at Virginia's laws regarding DDNR.  I think they only specify cardiopulmonary resuscitation.  Notice, I didn't write pulmonary resuscitation.  I wrote cardiopulmonary resuscitation, which includes at the ALS level ETT, drugs, CPR, etc.  In this case, I would treat the pt with everything you listed.  There is a lot of disparity between do not resuscitate orders and it’s certainly not cut and dry, so you really need to be up on you local laws and protocol.


----------



## Epi-do (Dec 4, 2006)

A DNR means "Do not resuscitate" not "Do not treat".  I have picked up more patients at nursing homes and been told "They have a DNR" than I can count.  Yes, that is info that I do need to know just incase the worse would happen, but if grandma is having an AMI, I am still going to follow my chest pain protocols.  I am not going to sit there and wait for her to die and not do anything.

That being said, if this patient is still alive then she deserves the best treatment she can be given within the provider's level of training and protocols.  Since I am a basic, that would mean high flow O2, requesting ALS, rapid transport to a level 1 trauma center in the meantime.  Since I am not allowed to clear c-spine, I would probably do that as well.  More of a CYA than anything.  Since the patient did fall and is unresponsive at the moment it would be justified.

As far as flying this patient, that would depend upon the specific guidelines laid out for doing so, as well as proximity to the hospital.  Around here, we have 2 Level 1's, both of them relatively close so going by ground may actually be quicker by time you factor in the time required to get the bird in the air, set up a landing zone, etc.


----------



## Guardian (Dec 4, 2006)

Depending on how far you are from a trauma center, I would consider flying and wouldn’t hesitate calling a helicopter.


----------



## Ridryder911 (Dec 4, 2006)

Does she have a "Living Will" or a DNR? There is a lot of difference. 

DNR means, do not resuscitate, that is ALL it means. It does not imply or mean "do no care". Legally if the patient is alive and you have failed to perform action as any other patient with the same injuries, you have performed neglected care for that patient, and  can and should be held liable. There has been successful law suits against EMS services for "age discrimination" because standard of care was failed to be carried out. 

If the patient has a "Living Will" with specific directions on what "should NOT be performed" ; such as intubation, tube feedings, water, medications, CPR etc... then yes I would honor them if they were still active and binding or the patient goes into an arrest, then yes I would stop resuscitation efforts. 

Each EMT needs to check and clarify local laws and standards in their area.


----------



## Guardian (Dec 4, 2006)

yep, the new buzzword is ageism.


----------



## jeepmedic (Dec 4, 2006)

Can a First Responder honor a DNR?


----------



## trauma1534 (Dec 4, 2006)

No, there was no living will.  It was just a DNR order.  I was advised by Sr. medic on the truck to stop all AMS precedures as the had this DNR.  I was in the process tubing when I got stopped.  Where we are, the Sr. provider on the truck in is in charge is it is on them whatever happends to the patient.  I don't agree!


----------



## trauma1534 (Dec 4, 2006)

jeepmedic said:


> Can a First Responder honor a DNR?




Jeep, they have to.  Anyone who is a health care provider even just CPR certified have to honor the DNR order.  

Just because they are entry level trained, they still have a responsibility.

Hope that helps!


----------



## jeepmedic (Dec 4, 2006)

:blush: 

:beerchug:


----------



## trauma1534 (Dec 4, 2006)

Guardian said:


> yep, the new buzzword is ageism.



Well, it may be new to you, but it's been the buzzword for me for 12 years!  It's bad!  It really should not be that way.  It should not matter who or what age they are, they deserve the same treatment!  I agree Guradian!


----------



## Ridryder911 (Dec 4, 2006)

Sounds like a tough call and situation.. Trauma1534. If it is bothering you, then something is wrong. Discuss this with the medic one on one, maybe he/she can give a better insight on their actions. If still uncomfortable, I would write an incidence report. Sorry, CYA and although nothing will probably come from this incidence, it might occur again with different situation. 

It is sometimes a judgement call, and not knowing all the facts, that is why I would discuss this with your partner first... 

R/r 911


----------



## trauma1534 (Dec 4, 2006)

Ridryder911 said:


> Sounds like a tough call and situation.. Trauma1534. If it is bothering you, then something is wrong. Discuss this with the medic one on one, maybe he/she can give a better insight on their actions. If still uncomfortable, I would write an incidence report. Sorry, CYA and although nothing will probably come from this incidence, it might occur again with different situation.
> 
> It is sometimes a judgement call, and not knowing all the facts, that is why I would discuss this with your partner first...
> 
> R/r 911



Well.. it was not my partner, this happened to be a medic who responded to assist us on this call.  I knew what I had and need addional ALS onboard.  So far, it would have only been me an EMT-B, and a driver.  When he arrived, he took it over because he was a Senior Medic.  He is one who you can't discuss anything with... I tried... Paragod, if you will.  It has been a hard thing to deal with for me as I am a very agressive provider and I have a hard time just setting there watching and waiting when I know what needs to be done.  Would our ALS efforts made much difference?  Probably not.  But it is the principal of it.


----------



## Guardian (Dec 4, 2006)

This person might need to be reminded of the laws regarding DNRs in your state.  Notice I didn't say protocols because what we are dealing with here is legislation.  DNR = legislation.  Get it?  Your medical director couldn't back you up on this one and the traditional ems hierarchy wouldn't mean much in court.  CYA is good, incident report would have been nice right after incident but not so much now.  Most important thing, discuss this with an authority in your system and get this crap straightened out so you won't have to deal with it again.


----------



## AnthonyM83 (Dec 5, 2006)

You still want to give them every bit of car you can, just specifically not whatever it says on the DNR "CPR" "IV" "ventilations".


----------



## jeepmedic (Dec 5, 2006)

Trauma didn't you say that the Son was on scene and told you to "Do what you can".
If  so:
After some research here is what I found out about the Virginia DNR Laws.

12 VAC 5-66-80 under section E. Revocation

"If the Patient is a minor or is otherwise incapable of making an informed decision, the expression of the desire that the patient be resuscitated by the person authorized to consent on the patient's behalf shall so revoke the qualified health care personnel's authority to folow a Durable DNR or other DNR Order."

So if in fact the Son told you to do what or all you can and he was the contact person for the Nursing Home then the DNR is Revoked per the LAW!!

So the medic was still wrong.


----------



## Pablo the Pirate (Dec 5, 2006)

DNR does NOT mean do not treat.  I would do everything i could for this pt including tubes, IVs, and flyin in a bird if i thought the bird was the quicker route.  As long as the pts heart is still beating on its own then she ain't dead and DNR has nothing to do with me at that moment in time. even if it states not to tube or use IVs or drugs or whatever.  now if said pt decided to code then DNR kicks in and treatment stops. until then she is just as human and alive as you and I.  I think the medic that stopped you from treating her is in the wrong and definatelty dont agree with not giving her the best care that you possibly can.


----------



## trauma1534 (Dec 5, 2006)

AnthonyM83 said:


> You still want to give them every bit of car you can, just specifically not whatever it says on the DNR "CPR" "IV" "ventilations".



But this is just referring to it being in a code situation, right?  Not a traumatic injury???


----------



## Guardian (Dec 5, 2006)

DNR's don't even come into play unless the person is in full arrest.  All DNR's I've seen say exactly this so if you actually take 2 mins to read the virginia dnr, i'm 99% sure that's what it will say.  In fact, it's been my experience that 90% of dnr questions can be cleared up just by reading the damn thing but we all know how ems providers are.


----------



## jeepmedic (Dec 5, 2006)

Guardian said:


> DNR's don't even come into play unless the person is in full arrest.  All DNR's I've seen say exactly this so if you actually take 2 mins to read the virginia dnr, i'm 99% sure that's what it will say.  In fact, it's been my experience that 90% of dnr questions can be cleared up just by reading the damn thing but we all know how ems providers are.



The Virginia DDNR Law covers Respiratory Arrest also.


----------



## Guardian (Dec 5, 2006)

jeepmedic said:


> Trauma didn't you say that the Son was on scene and told you to "Do what you can".
> If  so:
> After some research here is what I found out about the Virginia DNR Laws.
> 
> ...




Just be careful...was the son a POA?...this is a very murky area.


----------



## jeepmedic (Dec 5, 2006)

Guardian said:


> Just be careful...was the son a POA?...this is a very murky area.



She was unresponsive so an Adult Child can act as POA for medical treatment in Virginia as long as the pt's. spouse is not present.


----------



## Guardian (Dec 5, 2006)

jeepmedic said:


> The Virginia DDNR Law covers Respiratory Arrest also.



Ok, I'll take your word for it, I knew some did...thanks


----------



## Guardian (Dec 5, 2006)

jeepmedic said:


> She was unresponsive so an Adult Child can act as POA for medical treatment in Virginia as long as the pt's. spouse is not present.



Wow, I didn't know that, I wonder if that's unique to virginia or not.


----------



## Guardian (Dec 5, 2006)

jeepmedic said:


> She was unresponsive so an Adult Child can act as POA for medical treatment in Virginia as long as the pt's. spouse is not present.




Did the son sign the dnr, if not, his is probably not authorized to make this decision...I'm not a lawyer and Va could have a screwy law but nationally this is usually the case...if you want to make a decision then you have to have signed the dnr.


----------



## jeepmedic (Dec 5, 2006)

I don't know but the Virginia law has a list of people in order who can make Medical choices. It can get confusing(sp). If a family member defaces the DDNR then it is no longer valid. There are alot of different ways around a DDNR if the family wants to get around it. The more I research the law the more I don't Like it.  

For the record I would have Intubated her to secure her Airway. This is to prevent aspiration. There has been comments made that her airway was not compromised well that don't flush with me. How many times are 20 something year olds intubated because they have a head injury? (Everyone that has a provider that can intubate will). This is so that they do not compromise their airway. Not because their airway is already compromised. 

It has also been said that it didn't matter what was done it would not have changed the outcome of the pt.. Well I again think this is bull. You will never know. If the brain had have been given enough O2 then maybe. Who knows?

The bottom line is a Jr. ALS provider wanted to treat a pt. and was stopped by a Sr. Medic. And this was because the pt. had a DDNR. Which is not a Do Not Treat.

(Now my ears are red)


----------



## FFEMT1764 (Dec 7, 2006)

FUN!  This situation is tricky, because here in SC a DNR means no cardiac or respiratory skill (defib, ETT, CPR, or diagnostic monitoring). I would ventilate the patient with the BVM, as I am aonly assisting them, if the patient goes apneic it chages the parameters. I would be hesitant on calling the helicopter to transport as the trauma services here will not treat DNR patients like they would a non DNR person because of the way the laws were written. I  would take her to the level 1 center though. I would also give her IV fluids, and non cardiac related meds. DNR means no NTG,ASA, morphine for chest pain, Epi, Atropine, Lidocaine, Adenocard, Mag Sulfate, Ca, and the like. I can give NTG and morphine for CHF and pulmonary edema. I can also give the other drugs. I would treat this women to the utmost of my ablility while remaining in line with the law.  

In SC a DNR can only be revoked by distruction, alteration, mulitation, or an oral statement form the person who has the DNR. Family members don't count even if the are the POA, the exception being if they signed the DNR for their family member in the case where the patient in unable to comprehend their condition.


----------



## jeepmedic (Dec 8, 2006)

What happens to a pt that goes in for hip replacement Surg.? They get intubated. Even if they have a DDNR.


----------



## FFEMT1764 (Dec 8, 2006)

Most surgeons around here would not do a hip replacement on a patient with a DNR as they prolly wouldnt survive the surgery, let alone pass the perop screening.


----------



## trauma1534 (Dec 8, 2006)

FFEMT1764 said:


> Most surgeons around here would not do a hip replacement on a patient with a DNR as they prolly wouldnt survive the surgery, let alone pass the perop screening.



For the record, I work in the surgery at a level one trauma center, and they do surg everyday on DNR patients... and guess what?  Those patients get intubated during surgery!


----------



## prizonmedik (Dec 16, 2006)

IMHO  The DNR applies only to the terminal condition, not other trauma.  Anyway, I'd rather explain why I tried to save a person, than why I let them die.  And why was **** there anyway?


----------



## trauma1534 (Dec 16, 2006)

prizonmedik said:


> IMHO  The DNR applies only to the terminal condition, not other trauma.  Anyway, I'd rather explain why I tried to save a person, than why I let them die.  And why was **** there anyway?



He was called there per his father.  I was set to do everything possable for this patient, until "Mightymedic" showed up.  That's a whole other story that you well know without me getting into it.


----------



## firemedic (Jan 4, 2007)

*Dnr*

I think the key thing to remember is that DNR does not mean do not treat. I think that is a big misconception among nursing home staff and nurses in NY state. Of the nursing homes I respond to, that is one of the most frequent states, they have a dnr, never mind the fact that the patients pulse ox is in the 70's, or they are unresponsive. In NY, you still have to follow all protocols that apply/


----------



## yowzer (Jan 4, 2007)

firemedic said:


> I think the key thing to remember is that DNR does not mean do not treat. I think that is a big misconception among nursing home staff and nurses in NY state.



Washington has a standard form called the POLST (Physician's Orders for Life-Sustaining Treatment) that spells out just what treatment someone desires -- comfort measures, 'limited' interventions, IVs, antibiotics, tube feeding, the full meal deal of working a code, etc. It's really nice to have when it's filled out correctly. http://www.wsma.org/patients/polst.html has an online copy of the form. I think some other states (Ohio?) have adopted it too, or something similar.


----------

