# DNR, comfort measures, BVMs and OPAs



## TimBootz (Jul 23, 2011)

A question: I had a pt who was DNR and comfort measures only. The pt was a 77 y/o male w/ SOB 2^ to end stage COPD. This pt actually had a POLST with instructions pretaining to no intubation and was due to enter hospice care in 1 weeks time. I know that with comfort measures you can still admin O2 just no CPR.   When a pt is comfort measures only can you still assit ventilations with a BVM? can you use OPAs or NPA's or are you only suppose to use passive O2 such as a NRB. Fortunately this pt managed to maintain with a NRB @ 10 l/min till we reached the ER which was only 6 min away. Pt. was a medic eval cleared for BLS tx. I had the BVM ready in case. I know it is more defensable to do something rather then nothing but the call got me to thinking....


----------



## MrBrown (Jul 23, 2011)

Based on Brown's clinical and legal framework, no assisting ventilations is not "comfort measures"

Your framework may differ


----------



## TimBootz (Jul 23, 2011)

Mr Brown can you clarify. Are you saying that in your frame work assisting ventilations (and by extension OPAs) is not ok when a pt is comfort measures only?


----------



## JPINFV (Jul 23, 2011)

TimBootz said:


> I know it is more defensable to do something rather then nothing but the call got me to thinking....




Either can be equally defensible or indefensible based on what you knew and what a reasonable EMT would have known. I wouldn't think that a battery charge (or, which is more likely, the civil suite for any additional medical care received) in a case where a patient had a valid POLST/DNR order that a medical provider, including EMTs, knowingly disregarded without good cause (which is normally defined). Every set of protocols (be it service protocols, region, or state) should have a policy on how to handle patients with DNR, and if you haven't read it yet then that ignorance is your own fault, not your company's or your schools.


----------



## MrBrown (Jul 23, 2011)

Gosh mate "Mr Brown" sounds so formal, Brown or Your Royal Excellency will suffice 

We have significant legal and praxis differences than the US, we do not work to "protocols" and there is much discretion left up to the professional clinical judgement of the Ambulance Officers on scene.

In saying that, if a patient has a DNR, living will or clearly articulated advanced directive (verbal or written) or themselves makes the request they do not want any life sustaining measures it is inappropriate for us to initiate measures aimed at doing that - for example relief of pain is appropriate whereas IV fluid or assisted ventilation are not


----------



## usalsfyre (Jul 23, 2011)

So less a "legal" question and more a "moral" question, but WHY would you BVM this patient? The point of comfort care and DNR is that death is if not exactly welcome than an expected event.

Don't be 100% sure of how defensible wrongful recusitation.


----------



## TimBootz (Jul 23, 2011)

Forgive my "ignorance" of the issue,  which is why I am posting this here, in an effort to gain a better understanding of the issue, and what other BLS provider would consider prudent. The medics relased the pt to bls txpt because they said they would be unable to intubate the pt. 

The protocols for 2010 in my county pretaining to DNR are written like this,
after the lengthy secton on documentation 

"DNR" does not mean "do not care". A dying pt for whom no resuscitation effort is indicated can still be provided with support care, which may include the following:

Clear the airway (including stoma) of secretions
provide O2
control any bleeding
provide emotional support to pt and family
contact Pt MD
contact hospice if involved
Paramedics should be called if additional judgement or support is needed.

WHEN IN DOUBT, INTIATE RESUSCTATION (actually written in all caps and bold)

I have sent some emails out pretaining to the same question here in my county.

The call got me thinking that it is something that I need more information on for if/when confronted with the same situation in the future.


----------



## usalsfyre (Jul 23, 2011)

Ventilating a patient isn't really "providing O2". It's using artificial measures (in this case ventilations) to extend life. This is true whether it's through an endotracheal tube or a mask. 

Sorry for being contrite. It's not your fault EMS education is jacked.


----------



## Sasha (Jul 23, 2011)

Artifical ventilation is life support. So dont bag a DNR patient.

Sent from LuLu using Tapatalk


----------



## JPINFV (Jul 23, 2011)

TimBootz said:


> Forgive my "ignorance" of the issue,  which is why I am posting this here, in an effort to gain a better understanding of the issue,



There's nothing wrong with ignorance. I'm fairly ignorant of quantam mechanics and fire fighting myself (among plenty of other fields of ignorance). Ignorance also has the wonderful trait of being fixable. 




> and what other BLS provider would consider prudent. The medics relased the pt to bls txpt because they said they would be unable to intubate the pt.
> 
> The protocols for 2010 in my county pretaining to DNR are written like this,
> after the lengthy secton on documentation
> ...




Is positive pressure ventilation listed? Is there any doubt to the validity of the DNR? Did you try contacting hospice (just because the patient isn't "in hospice" doesn't mean they aren't receiving hospice care) or the patient's physician? Did you ask the paramedics about PPV? Is online medical control an option that you could avail yourself to (it isn't always an option...)? 

Additionally, you'll be surprised the amount of people who don't read the policy statements that are in the protocol book like this.


----------



## JPINFV (Jul 23, 2011)

usalsfyre said:


> Sorry for being contrite. It's not your fault EMS education is jacked.



Given that the applicability of DNRs can vary wildly (everywhere from "only the orange colored official "prehospital DNR" form counts to being able to take verbal requests from immediate family members), if someone doesn't look up their local policy regarding patients with DNRs then it isn't the fault of their education program.


----------



## bigbaldguy (Jul 24, 2011)

Just FYI dnr's are not generally honored on commercial aircraft unless lots of paperwork is done first.


----------



## BEorP (Jul 24, 2011)

bigbaldguy said:


> Just FYI dnr's are not generally honored on commercial aircraft unless lots of paperwork is done first.



Do you have a link to where I can read about this? It seems like by the time they could actually get the plane down, any further resuscitation efforts would be futile if the AED was already used without success.


----------



## Aidey (Jul 24, 2011)

I found WAs POLST form online. Seeing as BiPAP/CPAP are listed as limited interventions, I would take that to mean that BMV is definitely NOT comfort measures. I don't think a BVM, OPA or NPA falls under "manual treatment of airway obstruction". 
	

	
	
		
		

		
			





http://www.wsma.org/files/Images/PatientResources/Polst_form1.gif


----------



## ffemt8978 (Jul 24, 2011)

Aidey said:


> I found WAs POLST form online. Seeing as BiPAP/CPAP are listed as limited interventions, I would take that to mean that BMV is definitely NOT comfort measures. I don't think a BVM, OPA or NPA falls under "manual treatment of airway obstruction".
> 
> 
> 
> ...


Correct, although most POLSTs that I've seen usually detail what is acceptable for airway measures.


Sent from my Android Tablet using Tapatalk


----------



## TimBootz (Jul 24, 2011)

Thank you that clears things up. I had not thought of it in the sense of CPAP and BiPAP, being they are machines as opposd to a BVM which is manual.

What I was thinking with my pt was he was still A+O spaeking in 2 word sentences (so havig a conversation with him was not really an option just yes and no questions) and had incresed work of breathing with diminshed volume and incresed resps. The pt was also doing a home neb treatment when I arrived on scene. I had always considered DNR and "after they stopped breathing or their heart stopped" measures. 

I am also going to have a discussion with my companies med director when I get back on rotation next week.

Thank you for all the replies.


----------



## Aidey (Jul 24, 2011)

The POLST form is not just a DNR though. Section B specifically states "Person has pulse and/or is breathing".


----------



## bigbaldguy (Jul 24, 2011)

BEorP said:


> Do you have a link to where I can read about this? It seems like by the time they could actually get the plane down, any further resuscitation efforts would be futile if the AED was already used without success.



Just what I was taught at my airline and what folks at other airlines are taught as well. It is actually fairly common for a passengers family to Present a DNR before a flight. I've only seen one DNR presented at gate that we were told to "honor" by the higher ups and this was because a long process of paper work had been taken care of. I think the main reason for this is that as flight attendants we do not have the knowledge to decide if a DNR is valid or not. Theoretically we can call the medical advisor to verify the validity of a DNR but by the time a patch was made we would most likely have either successfully used the AED or there would be no point. I know we had a situation a few years back where a DNR was presented by family when a passenger died on a flight. The crew tried to perform CPR Ect.. The family was not happy but since the crew are considered lay responders there were no repercussions. 
It does bring up the interesting question of what I would do if I was on a flight with a pax who coded and a DNR was presented. step back and let my crew do their thing I guess.


----------



## ArcticKat (Jul 24, 2011)

*Here's my take*

My rule of thumb is that if I have to put something into the patient, it is not a "Comfort Measure", it's a treatment.  Putting in an OPA, or using a BVM to put in air, would not be a comfort measure in my books and therefore exceeding the requests of the patient.

Administering oxygen via NRB or NC is a comfort measure.  Hydrating PO is a comfort measure.

The only situation where I relax this rule of thumb is IV access for medications and hydration and foley caths.


----------



## ffemt8978 (Jul 24, 2011)

Aidey said:


> The POLST form is not just a DNR though. Section B specifically states "Person has pulse and/or is breathing".



And Section A has a specific section about no pulse/not breathing.


----------



## crazycajun (Jul 24, 2011)

TimBootz said:


> Thank you that clears things up. I had not thought of it in the sense of CPAP and BiPAP, being they are machines as opposd to a BVM which is manual.
> 
> What I was thinking with my pt was he was still A+O spaeking in 2 word sentences (so havig a conversation with him was not really an option just yes and no questions) and had incresed work of breathing with diminshed volume and incresed resps. The pt was also doing a home neb treatment when I arrived on scene. I had always considered DNR and "after they stopped breathing or their heart stopped" measures.
> 
> ...



DNR orders are fairly simple. OPA, NPA, ETT are considered advanced airway and cannot be used. BVM is for assisted ventilation and is also not allowed. If your PT is DNR w/ comfort measures only all you can do as a basic is give O2 via NC or NRB, use jaw thrust or head tilt to clear airway and comfort the PT along with family to the best of your ability. Any other methods could be construed as a violation against the order. Now if your PT is suffering from anything other than the disease in which the DNR is written for that is a different story. Like if your PT was choking on a piece of meat you could use advanced care because it is not the terminal disease killing him.


----------



## Shishkabob (Jul 24, 2011)

An OPA and NPA, atleast here in Texas, are not considered advanced airways.  I've put plenty of OPA's and NPAs in DNR patients without anyone so much as batting an eye.



Their DNR is in effect for ANYTHING that may kill them, not just their terminal disease it's written for.  If they have hepatic cancer, but die from some other natural cause, you still are not to do anything.



The exception to this, as written word for word on the Texas OOH-DNR, is "This Out-of-Hospital DNR order is automatically revoked if the patient is known to be pregnant or in the case of unnatural or suspicious circumstance"

IE, if they are the victim of a crime, the DNR is not valid.


----------



## TimBootz (Jul 24, 2011)

Interesting. Here in my county we are not allowed NPAs and OPAs are also not considered advanced airways like King, Combitubes or ETT.


----------



## Tigger (Jul 25, 2011)

crazycajun said:


> DNR orders are fairly simple. OPA, NPA, ETT are considered advanced airway and cannot be used. BVM is for assisted ventilation and is also not allowed. If your PT is DNR w/ comfort measures only all you can do as a basic is give O2 via NC or NRB, use jaw thrust or head tilt to clear airway and comfort the PT along with family to the best of your ability. Any other methods could be construed as a violation against the order. Now if your PT is suffering from anything other than the disease in which the DNR is written for that is a different story. Like if your PT was choking on a piece of meat you could use advanced care because it is not the terminal disease killing him.



I'd be careful about making blanket statements regarding DNRs. It is up to the individual states to create their own DNR protocol, and deviations among states certainly exist. For instance, the MA DNR is not written to include any specific medical condition. If the patient is in extremis and has a valid DNR, providers are not to attempt resuscitation. 

Furthermore, in MA, palliative care is to be given to patients who are experiencing a medical emergency but still has a pulse and is breathing. This  includes among other things, suctioning, IV initiation, and 12 leads.  

I guess the take away here is: understand what _your_ state's DNR protocol is.


----------



## JPINFV (Jul 25, 2011)

Tigger said:


> Furthermore, in MA, palliative care is to be given to patients who are experiencing a medical emergency but still has a pulse and is breathing. This  includes among other things, suctioning, IV initiation, and 12 leads.
> 
> I guess the take away here is: understand what _your_ state's DNR protocol is.



Also, understand the nuances. For example, acute, non-related conditions, are often ok to treat. The typical example given is giving the heimlick to a patient with a FABO. Similarly, I'd argue that administering D50 to a hypoglycemic patient would be perfectly ethical.


----------



## Aidey (Jul 25, 2011)

ffemt8978 said:


> And Section A has a specific section about no pulse/not breathing.



So like I said, it isn't only a DNR. 

To the OP, it may be easier to think of the POLST form as two different forms.


----------



## Tigger (Jul 25, 2011)

JPINFV said:


> Also, understand the nuances. For example, acute, non-related conditions, are often ok to treat. The typical example given is giving the heimlick to a patient with a FABO. Similarly, I'd argue that administering D50 to a hypoglycemic patient would be perfectly ethical.



I would agree that D50 adminstration should be considered pallitave care since it would serve to make the patient more comfortable. That said any drug administration for someone with a DNR requires contacting medical control, from what I understand.


----------



## TimBootz (Jul 27, 2011)

I have found the anwser I was looking for by going throught the CBT moduals. I have not yet taken the death and dying CBT but here is quote from it..

"The Dying Patient
On rare occasions, a patient with a terminal illness clearly may be dying on your arrival, but not yet in cardiac arrest. If the patient has requested that no resuscitation be performed, you should honor those wishes if cardiac arrest occurs. For example, you would withhold aggressive treatment such as chest compressions, bag-valve-mask ventilation or defibrillation. Always ask the patient or surrogate...Palliative Care
You can make a patient more comfortable with appropriate positioning, suctioning or controlling bleeding."


Thank you for everyones posts


----------



## katgrl2003 (Jul 27, 2011)

Tigger said:


> I would agree that D50 adminstration should be considered pallitave care since it would serve to make the patient more comfortable. That said any drug administration for someone with a DNR requires contacting medical control, from what I understand.



Why? DNRs are for when the heart stops or when they stop breathing. There are lots of things they cant have wrong that requires a medication you can give. Example: pain relief. We don't call for orders for pain relief with regular patients, and they only way I can see to call on a DNR patient is if they already have lots of pain meds on board.


----------



## parapaulieFL (Jul 27, 2011)

Yeah it depends on each state. It sucks as a health care provider to watch a patient slowly die and not be able to do anything about it. The majority of DNR patients I have taken are in a hospice type care program and expect the outcome. The main issue is most people know this is coming and do not care to prolong the pain or suffering any longer. I have had a lot of these patients die en route, all you can do is make them comfortable.


----------



## Akulahawk (Jul 27, 2011)

parapaulieFL said:


> Yeah it depends on each state. It sucks as a health care provider to watch a patient slowly die and not be able to do anything about it. The majority of DNR patients I have taken are in a hospice type care program and expect the outcome. The main issue is most people know this is coming and do not care to prolong the pain or suffering any longer. I have had a lot of these patients die en route, *all you can do is make them comfortable*.


Which is the reason they're in hospice. For all of us, the end is inevitable. It's just a question of when and how. If I'm going to kick the bucket from some reason other than old age where one day I just "wake up dead" I would want some kind of comfort care to keep me comfortable while on my way out. Today, the dying process can be so drawn out, it's difficult to see when that final downward spiral begins in earnest. It used to be pretty obvious that someone was "on their deathbed."


----------



## Tigger (Jul 27, 2011)

katgrl2003 said:


> Why? DNRs are for when the heart stops or when they stop breathing. There are lots of things they cant have wrong that requires a medication you can give. Example: pain relief. We don't call for orders for pain relief with regular patients, and they only way I can see to call on a DNR patient is if they already have lots of pain meds on board.



Honestly, the best answer I can give is that it states exactly that in our statewide protocols. Whether or not this followed is beyond me, I work on a BLS truck and have yet to give anyone a BLS medication beyond prescribed oxygen to someone with a DNR. The paramedic crews may operate differently.


Sent from my out of area communications device.


----------



## HotelCo (Jul 27, 2011)

If I, as a 21 year old male, have a valid DNR, and it's presented, or known to you, when I call 911 for a medical emergency, would you treat me if I had the following: (each one is to be considered a separate scenario)

Hypoglycemia?

Asthma?

Some sort of major trauma? 

Respiratory arrest? What if you thought it was due to a narcotic OD?


Sent from my iPhone using Tapatalk


----------



## JPINFV (Jul 27, 2011)

HotelCo said:


> Hypoglycemia?
> 
> Asthma?
> 
> ...




Yes. 

Yes. 

Depends on the situation (before yellows, but at the end of the reds if multiple patients are present).

Depends (Causes immediately reversible such as narcotic ODs, however with the caveat that narcotic ODs due to pain management concerns, in contrast to accidental OD, would not be treated). Pretty much every DNR policy I've seen has directed providers to provide pain control even if it meant shortening the patient's life.


----------



## Akulahawk (Jul 28, 2011)

I'd have to have paperwork _or_ the medallion before I'd withhold care... if at all. My specific responses in red below.


HotelCo said:


> If I, as a 21 year old male, have a valid DNR, and it's presented, or known to you, when I call 911 for a medical emergency, would you treat me if I had the following: (each one is to be considered a separate scenario)
> 
> Hypoglycemia? Yes.
> 
> ...


All this assumes that I have legal evidence of your DNR status _PRIOR _to treating you.


----------



## JPINFV (Jul 28, 2011)

> Asthma? Yes if your DNR is not related to respiratory issues.




You know... I'd go as far as saying that a quick albuterol tx would be a comfort care treatment.


----------



## Akulahawk (Jul 29, 2011)

JPINFV said:


> You know... I'd go as far as saying that a quick albuterol tx would be a comfort care treatment.
> [/COLOR]


Being that the DNR policies I've seen specified cardiotonic drugs, if I had a patient who had a DNR and asthma and was having difficulty breathing because of the asthma, I'd right there with ya, for the same reason. The only reason I put in the "DNR not related to respiratory issues" was to address the possibility that someone's respiratory problems were the cause of the DNR/Care order that specifies that no respiratory meds were to be given... 

Of course, then again, where's the line that we stop at? After all, isn't mag sulfate used in treating asthma? Since it's also used in cardiac resuscitation, is it "out" if it's used primarily for treating asthma in that instance? 

Albuterol nebs I'm good with, but should that be limited to 2 or 3 treatments or is continuous neb Tx OK? 

I guess it comes down to intent. If I intend to make the patient more comfortable, it's good but if the intent is to prevent a respiratory failure caused code... then I can't "do that" and provide whatever comfort care methods I'd have at my disposal.


----------



## JPINFV (Jul 29, 2011)

Akulahawk said:


> Albuterol nebs I'm good with, but should that be limited to 2 or 3 treatments or is continuous neb Tx OK?
> 
> I guess it comes down to intent. If I intend to make the patient more comfortable, it's good but if the intent is to prevent a respiratory failure caused code... then I can't "do that" and provide whatever comfort care methods I'd have at my disposal.


I think these are the two big issues, how long does the treatment need and intent. Furthermore, it's a judgement call. I wouldn't say that a continuous neb would be appropriate, but how many before you stop is going to be situationally dependent.


----------

