# Rookie question on DNRs



## Old Tracker (Mar 27, 2016)

I'm asking here because I didn't think to ask the other EMTs on that run, at the time.

We had a 90 year old man, COPD, who called with breathing difficulties. Daughter showed us a valid DNR for cardiac arrest. Vitals, all except respiration rate were within limits. They agreed to transport the patient to the hospital. Vitals got better with O2 on the way to the hospital.

The question is, if he would have started to go into arrest, enroute, do we treat, or is it a hands off situation since we have seen the DNR.

My thought is to intervene with the intention of preventing the arrest, but I am not sure.

Thanks.


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## COmedic17 (Mar 27, 2016)

A DNR means do not resuscitate, not "kill me". 

 Oftentimes  DNR's will be comfort care only ( no intubation, no surgery, no tube feelings, etc) but that will be listed. If it's something as simple has throwing on a couple liters and there's not some written request asking you not to, do it.


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## Old Tracker (Mar 27, 2016)

Thank you, that's what I thought.


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## johnrsemt (Mar 28, 2016)

When I worked in Indiana, on the street all we could honor with DNR's was all or Nothing:  we couldn't honor:  drugs, but no compressions (which I always thought was stupid anyway, 'lets load up your arm with Epi but not circulate it anywhere')
Here in Utah we can honor multiple levels of DNR.  Which can get weird.   I saw one that allowed Drugs, Compressions, but no oxygen.


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## wanderingmedic (Mar 28, 2016)

Most of the time how DNR's are handled is state and local protocol dependent. If the patient can communicate, ask them tactfully! Simple yes and no questions like: "sir, I see you have a do not resuscitate order here, would you like us and the hospital to continue to follow it?" can be helpful. 

Remember, the power of attorney (the patient if they are AOx4) can revoke a DNR, so the best course of action is to talk with them about what they would like. Provide comfort and supportive care regardless, and contact OLMC with questions. OLMC can also be a great resource if you aren't sure how to best create a treatment plan that honors the DNR. If the patient and/or family only wants transport, but no treatment, I make them sign a refusal of EMS treatment and explain what that entails prior to transporting. Communication with DNR's is key. Just talk it out with the patient and family, and contact OLMC if necessary.


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## Gurby (Mar 28, 2016)

Old Tracker said:


> I'm asking here because I didn't think to ask the other EMTs on that run, at the time.
> 
> We had a 90 year old man, COPD, who called with breathing difficulties. Daughter showed us a valid DNR for cardiac arrest. Vitals, all except respiration rate were within limits. They agreed to transport the patient to the hospital. Vitals got better with O2 on the way to the hospital.
> 
> ...



In this situation, you need to take the DNR with you.  If he went into cardiac arrest and you didn't have the physical piece of paper in your hand, you'd still need to work it as if the DNR didn't exist.


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## Old Tracker (Mar 28, 2016)

Thank you guys, I'm reasonably certain a similar situation will occur again.


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## Akulahawk (Mar 28, 2016)

Old Tracker said:


> I'm asking here because I didn't think to ask the other EMTs on that run, at the time.
> 
> We had a 90 year old man, COPD, who called with breathing difficulties. Daughter showed us a valid DNR for cardiac arrest. Vitals, all except respiration rate were within limits. They agreed to transport the patient to the hospital. Vitals got better with O2 on the way to the hospital.
> 
> ...


You do a couple things... one is you honor the DNR as written in your policies. The SOB patient still gets oxygen but you can't usually pull out the BVM and actively breathe for them. If the patient arrests enroute, you follow the DNR that you have in hand. If you do not have it in hand, you don't have anything because who is to say later that the family didn't show you the DNR. If the family has "the only copy" you simply tell them you must take it with you and they can retrieve it once you arrive at the hospital. That's non-negotiable as I will protect my cert/license from prosecution and/or civil suit that very well could arise from me not having it around when that patient arrests and I withhold care pursuant to the DNR/POLST.


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## Old Tracker (Mar 28, 2016)

Thank you, sounds like excellent advice, I appreciate it.


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## ORcowgrrl (Apr 28, 2016)

We had a DOA at the hospital during my clinical rotations; a DNR was produced then and there, so logistically the situation actually panned out really well. The hospital staff was discussing it afterwards; if the present family members hadn't produced a DNR, but still requested we did not resuscitate...would we? They were discussing how legalities change somewhat once you're no longer in the pre-hospital setting, but I digress. DNR's are a wonderfully sticky subject.


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## OCemt86 (Jul 4, 2016)

ORcowgrrl said:


> We had a DOA at the hospital during my clinical rotations; a DNR was produced then and there, so logistically the situation actually panned out really well. The hospital staff was discussing it afterwards; if the present family members hadn't produced a DNR, but still requested we did not resuscitate...would we? They were discussing how legalities change somewhat once you're no longer in the pre-hospital setting, but I digress. DNR's are a wonderfully sticky subject.



That would be a county protocol thing. Here in orange county CA, if patient is in cardiac arrest and immediate family are there and unanimously agree to allow natural death to occur, then we can. Assuming no prior PROPERLY filled out POLST, ADR, or Electronic Orders are present.


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## floridamed224 (Aug 26, 2017)

I had a situation recently where I was transporting a hospice pt who had a DNR.  She was alert and oriented x4.  She became hypotensive en route.  I told her what was going on and she agreed with me that I should administer fluids.  We got her BP up but I went to drop her off at the hospice facility they had a fit.  They couldn't believe I would start and IV and give fluids to someone with a DNR.  They didn't know what to do.  They ended up calling the medical director for the facility to get advice.  They were so mad.  I guess I should have just let a conscious pt bottom out and die.
However sometimes I feel that there is a thin line between what to do in certain situations with a DNR present.  What if the pt wasn't conscious and unable to agree to the fluids?  Could you pace a pt with a DNR who became bradycardiac?


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## cprted (Aug 26, 2017)

DNRs, Level of Intervention forms, Advanced Directives, Living Wills ... can get very complex and the laws surround them vary from place to place.

In my area, we still have the DNR forms which are basically Yes CPR or No CPR. But the ones I actually prefer are a Level of Intervention form.  They lay what types of interventions the patient wishes.  Do they want the full meal deal, or just comfort measures?  They can also choose standard care, but no critical care interventions, etc. We also don't actually need to have the DNR in our hands ... if we "reasonably believe" a DNR exists, then we can honour it. As well, family members can direct us to ignore the DNR in some circumstances. Yeah, it gets muddy really quick. 



> I had a situation recently where I was transporting a hospice pt who had a DNR. She was alert and oriented x4. She became hypotensive en route. I told her what was going on and she agreed with me that I should administer fluids. We got her BP up but I went to drop her off at the hospice facility they had a fit. They couldn't believe I would start and IV and give fluids to someone with a DNR. They didn't know what to do. They ended up calling the medical director for the facility to get advice. They were so mad. I guess I should have just let a conscious pt bottom out and die.
> However sometimes I feel that there is a thin line between what to do in certain situations with a DNR present. What if the pt wasn't conscious and unable to agree to the fluids? Could you pace a pt with a DNR who became bradycardiac?



It's a super grey zone. Why do they have a DNR? What is the progression of their disease. Up here, people don't usually get admitted to hospice until they're getting to the end of the road. So carrying a hospice patient? Personally, I don't think I'd intervene there depending on what was going on. But the guy who lives at home and has a DNR because he just got Dx with cancer, but treatments are ongoing. To me that's a different patient.


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## hometownmedic5 (Aug 26, 2017)

Can you define for me "starts to arrest"?


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## Dennhop (Aug 26, 2017)

hometownmedic5 said:


> Can you define for me "starts to arrest"?



Duh...the heart starts to stop working.


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## VFlutter (Aug 26, 2017)

Most DNRs only address cardiac arrests and do not specify interventions outside of that. As said before it does not mean do not treat. Usually people will have advanced directives that state no life prolonging or invasive procedures. But many people with a DNR still want some level of care i.e antibiotics, fluids, etc.


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## hometownmedic5 (Aug 27, 2017)

The whole system is lacking in the specificity needed to make it workable. 

Until recently, Massachusetts only had a CPR or no CPR type system. Then the MOLST(Medical Orders for Life Sustaining Treatment) was created, which has a much higher degree of specificity, but is still lacking.


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## EMTlash (Oct 2, 2017)

Old Tracker said:


> I'm asking here because I didn't think to ask the other EMTs on that run, at the time.
> 
> We had a 90 year old man, COPD, who called with breathing difficulties. Daughter showed us a valid DNR for cardiac arrest. Vitals, all except respiration rate were within limits. They agreed to transport the patient to the hospital. Vitals got better with O2 on the way to the hospital.
> 
> ...


DNR's are always in the grey area, like almost everything else in EMS. But if the pt codes and you are a BLS unit w no medic on board then you would get ALS and the Base and start and then go from there. But usually BLS units do start a full work up.


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## hometownmedic5 (Oct 2, 2017)

EMTlash said:


> DNR's are always in the grey area, like almost everything else in EMS. But if the pt codes and you are a BLS unit w no medic on board then you would get ALS and the Base and start and then go from there. But usually BLS units do start a full work up.



Whoa. hang on a minute here. I've been up for like 40 hours and I may not be reading this right; but are you saying that as a basic, if presented with a valid DNR, you would work the patient until ALS arrived? Did I read that right?


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## DesertMedic66 (Oct 2, 2017)

hometownmedic5 said:


> If you have a valid dnr, you don't start recusitat
> 
> 
> Whoa. hang on a minute here. I've been up for like 40 hours and I may not be reading this right; but are you saying that as a basic, if presented with a valid DNR, you would work the patient until ALS arrived? Did I read that right?


That’s what I read it as also..


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## EMTlash (Oct 2, 2017)

hometownmedic5 said:


> Whoa. hang on a minute here. I've been up for like 40 hours and I may not be reading this right; but are you saying that as a basic, if presented with a valid DNR, you would work the patient until ALS arrived? Did I read that right?


I personally wouldn't but I have seen some BLS units doing it


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## hometownmedic5 (Oct 3, 2017)

Well your post certainly implies otherwise. Nonetheless, I apologize for casting aspersions on your practice.


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## EMTlash (Oct 3, 2017)

hometownmedic5 said:


> Well your post certainly implies otherwise. Nonetheless, I apologize for casting aspersions on your practice.


No problem man I'm sorry I should have worded it better


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## PassionMedic (Oct 5, 2017)

wanderingmedic said:


> If the patient can communicate, ask them tactfully! Simple yes and no questions like: "sir, I see you have a do not resuscitate order here, would you like us and the hospital to continue to follow it?" can be helpful.



I would also add: don't be afraid of this conversation (but still be tactful!) as these patients or families have made the decision for end of life care, they know what it means.  I usually ask ' Do you have any advanced directives?' If they look at me sideways, I follow up with 'If your heart stops do you want us to do CPR, breathe for you and give you medications, or cease efforts?' Don't be afraid to be a little blunt, especially if they don't want you taking the only copy of the DNR and you require it to honor it "sir, I understand this is your mother's only copy, but if we don't have it in hand, and god forbid her heart stops on the way, I can not honor her wishes"


Sent from my iPhone using Tapatalk

**edit- dear god, I didn't realize this was a dead thread! It popped up on my feed for some reason!


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