# DNR - NO Artificial Ventilation and the use of a BVM?



## Jtreon (Dec 25, 2013)

So here is my situation and wanted to get people's opinion on a situation I encountered.  I ran a call with a patient with respiratory distress and a valid DNR.  In route to the ER I had the pt on oxygen @ 6 LPM via nasal cannula and on top of that I was switching back and forth between giving A&A treatments with a misty Nebulizer and a NRB @ 15 LPM.  This way the pt was never with out oxygen.  My QA/QI department told me that I should have used a BVM to get a better seal and higher oxygen saturation, and I told them I do not feel comfortable using a BVM on a patient with a DNR due to the "NO Artificial Ventilations".  Even if I do not squeeze that bag and ventilate the pt does not mean that everyone else would question if I did ventilate the patient! So I guess my question for the masses is what is your thoughts on this, do you feel comfortable putting your self in question, am I wrong about not using a BVM, am I not understanding the DNR correctly?  Even legal views on what to and not to do as of CYA type of thing, remember I work in Texas if that changes any legal standings...


----------



## unleashedfury (Dec 25, 2013)

So they wanted you to place the mask on their face, but do not ventilate them? 

If your that far down the hill.. why not CPAP?


----------



## Wheel (Dec 25, 2013)

unleashedfury said:


> So they wanted you to place the mask on their face, but do not ventilate them?
> 
> If your that far down the hill.. why not CPAP?



I would have considered CPAP as well in this situation I think.


----------



## Jtreon (Dec 25, 2013)

My thought was giving medications to open up the airway only switched to NRB to increase Oxygen%


----------



## unleashedfury (Dec 25, 2013)

I grasp your concept. but if your giving meds to open the airway up some, assuming your giving albuterol, and the first treatment was unsuccessuful patient saturations are still in the toilet, and you moved up to the NRB, keep going to improve saturations. CPAP in line albuterol is your friend. 

Solumedrol and Decadron can be your friends but they take forever to work.


----------



## Wheel (Dec 25, 2013)

unleashedfury said:


> I grasp your concept. but if your giving meds to open the airway up some, assuming your giving albuterol, and the first treatment was unsuccessuful patient saturations are still in the toilet, and you moved up to the NRB, keep going to improve saturations. CPAP in line albuterol is your friend.
> 
> Solumedrol and Decadron can be your friends but they take forever to work.



I actually gave an inline neb tonight. Worked wonders.


----------



## unleashedfury (Dec 25, 2013)

Wheel said:


> I actually gave an inline neb tonight. Worked wonders.



I did a code, a Lethargy call which i think was a accidental beta blocker OD since her heart rate was in the low 40's. and she said she screws up her meds all the time. And some dudes varicose vein decided to rupture and squirt like ol faitful. Not a bad night. But the SNF hates when I get a release on Codes.


----------



## Akulahawk (Dec 25, 2013)

Jtreon said:


> So here is my situation and wanted to get people's opinion on a situation I encountered.  I ran a call with a patient with respiratory distress and a valid DNR.  In route to the ER I had the pt on oxygen @ 6 LPM via nasal cannula and on top of that I was switching back and forth between giving A&A treatments with a misty Nebulizer and a NRB @ 15 LPM.  This way the pt was never with out oxygen.  My QA/QI department told me that I should have used a BVM to get a better seal and higher oxygen saturation, and I told them I do not feel comfortable using a BVM on a patient with a DNR due to the "NO Artificial Ventilations".  Even if I do not squeeze that bag and ventilate the pt does not mean that everyone else would question if I did ventilate the patient! So I guess my question for the masses is what is your thoughts on this, do you feel comfortable putting your self in question, am I wrong about not using a BVM, am I not understanding the DNR correctly?  Even legal views on what to and not to do as of CYA type of thing, remember I work in Texas if that changes any legal standings...


That's a situation where CPAP (if available) with in-line nebs should work well. Using the mask part of the BVM would work, but I see issues with maintaining a seal while also allowing for the neb to work OR the oxygen to continue flowing and allowing YOU the ability to continue assessing the patient's status.

If you don't have access to CPAP, you then should do what you did: Non-rebreather mask with nebs. The DNR does limit the interventions that you can use unless the patient rescinds the DNR. 

That's my 2 bits!


----------



## mycrofft (Dec 25, 2013)

If a DNR precluding artificial _*ventilation*_ is in force, any measure creating  positive pressure of viable gasses (O2, room air) would be precluded.
 A passive mask or cannula dependent upon the pt having independent respirations would not.


----------



## Carlos Danger (Dec 25, 2013)

Jtreon said:


> So here is my situation and wanted to get people's opinion on a situation I encountered.  I ran a call with a patient with respiratory distress and a valid DNR.  In route to the ER I had the pt on oxygen @ 6 LPM via nasal cannula and on top of that I was switching back and forth between giving A&A treatments with a misty Nebulizer and a NRB @ 15 LPM.  This way the pt was never with out oxygen.  My QA/QI department told me that I should have used a BVM to get a better seal and higher oxygen saturation, and I told them I do not feel comfortable using a BVM on a patient with a DNR due to the "NO Artificial Ventilations".  Even if I do not squeeze that bag and ventilate the pt does not mean that *everyone else would question if I did ventilate the patient!* So I guess my question for the masses is what is your thoughts on this, do you feel comfortable putting your self in question, am I wrong about not using a BVM, am I not understanding the DNR correctly?  Even legal views on what to and not to do as of CYA type of thing, remember I work in Texas if that changes any legal standings...



Well, NOT using the BVM that still got your actions questioned, didn't it? People will ALWAYS be able to question why you did or didn't do something. In that regard, you are damned if you do and damned if you don't. So you might as well just do what is right and worry about the explanations later.

As long as you do what is right for the patient and document your actions and the rationale for your actions, you are good to go. That doesn't mean you'll never be questioned, it means you will have done the best you can do to both care for your patient and defend your actions later, if need be. 


FWIW, I seriously question whether any clinically significant benefit is offered by a BVM vs. a NRB anyway. I know a BVM with a good seal can theoretically deliver 90% 02 vs. the 70% (maybe 80% on a good day) you might get with a NRB, but that 90% is best case scenario, meaning you consistently maintain a great seal and have *no* room air entrainment. Realistically I don't see anyone maintaining a perfect seal consistently throughout transport - especially when you are giving nebs, etc. So a NRB makes much more sense to me. Now if you are preoxygenating prior to an intubation attempt it makes sense to use a BVM, because you are motionless and you need to have the BVM out anyway. But during transport I don't think you are likely to be able to maintain the kind of seal you need to reap the added Fi02 available from the BVM.


----------



## jefftherealmccoy (Dec 26, 2013)

From the sounds of the DNR I would think a BVM would be opposing the pt's wishes.  In any case, sounds like a situation where I'd call my medical control doc and put the liability on him.  

We deal with DNR's and living wills a lot and honestly, most of the time I'm on the phone with the doc and then documenting the crap out of what they tell me to do.


----------



## Epi-do (Dec 26, 2013)

I am not going to comment about treatment of this patient, since everyone else has pretty much covered that angle.

The point that I want to make is that you stated this is a DNR and the patient is in respiratory _distress_.  Therefore, I am going to assume they still have a respiratory drive and a pulse.  Since a DNR only covers what is to be done in the event of a resuscitation, it isn't even in play at this point.  I know it gets said all the time, but Do Not Resuscitate does not mean Do Not Treat.  Do what is best for this patient to assist in improving his/her respiratory status.


----------



## jefftherealmccoy (Dec 26, 2013)

I don't know if there are other states that are the same, but there are different levels of DNR where I work.  It's also called a POST form (physicians orders for scope of treatment).  It can call for IV fluids, antibiotics, intubation, o2, or specific treatments OR complete lack thereof.  normally we go by what the POST says unless family requests something different.  In which case we'll either do what family asks or contact OMC.


----------



## Rialaigh (Dec 27, 2013)

Epi-do said:


> I am not going to comment about treatment of this patient, since everyone else has pretty much covered that angle.
> 
> The point that I want to make is that you stated this is a DNR and the patient is in respiratory _distress_.  Therefore, I am going to assume they still have a respiratory drive and a pulse.  Since a DNR only covers what is to be done in the event of a resuscitation, it isn't even in play at this point.  I know it gets said all the time, but Do Not Resuscitate does not mean Do Not Treat.  Do what is best for this patient to assist in improving his/her respiratory status.



If a DNR states no artificial respirations I think it is safe to assume that means before the patient codes 

Because if it meant no artificial respirations after the patients codes then...well...wouldn't that be a moot point. 


If a patient NEEDS a BvM they are in respiratory failure and not just distress. If they are in respiratory failure then we consider that a condition needing resuscitation. And thus...the DNR is valid and no positive pressure ventilation will occur.


----------



## mycrofft (Dec 27, 2013)

Rialaigh said:


> If a DNR states no artificial respirations I think it is safe to assume that means before the patient codes
> 
> Because if it meant no artificial respirations after the patients codes then...well...wouldn't that be a moot point.
> 
> ...



Don't we resuscitate after the pt codes? And we stop after declaration?


----------



## Carlos Danger (Dec 27, 2013)

Rialaigh said:


> If a patient NEEDS a BvM they are in respiratory failure and not just distress. If they are in respiratory failure then we consider that a condition needing resuscitation. And thus...the DNR is valid and no positive pressure ventilation will occur.



Right, but the OP wasn't talking about delivering positive pressure ventilation; he was referring to using the BVM as an oxygen delivery device. Or at least that's how I understood what he wrote.

Respiratory "distress" vs. "failure" is semantics in these situations. Either the patient wants mechanical ventilation or not. Ideally, that would be spelled out in the advanced directive, of course, but it isn't always clear. 

If the advanced directive is a simple "DNR", then traditionally that means do everything up until they arrest, but once they stop breathing or lose a pulse then do nothing at all. If they don't want mechanical ventilation or intubation BEFORE arresting, then that needs to be spelled out separately from the DNR.


----------



## Rialaigh (Dec 27, 2013)

Halothane said:


> Right, but the OP wasn't talking about delivering positive pressure ventilation; *he was referring to using the BVM as an oxygen delivery device.* Or at least that's how I understood what he wrote.
> 
> Respiratory "distress" vs. "failure" is semantics in these situations. Either the patient wants mechanical ventilation or not. Ideally, that would be spelled out in the advanced directive, of course, but it isn't always clear.
> 
> If the advanced directive is a simple "DNR", then traditionally that means do everything up until they arrest, but once they stop breathing or lose a pulse then do nothing at all. If they don't want mechanical ventilation or intubation BEFORE arresting, then that needs to be spelled out separately from the DNR.



Ah, well in that case I wouldn't bother using a BvM. The amount of oxygen you are going to deliver (while higher in theory) will make no practical difference in a patient that needs more O2 than a NRB can supply. It's kind of like saying a 12 gauge needle would deliver more fluid faster in a trauma patient then a 14.....


----------



## Rialaigh (Dec 27, 2013)

mycrofft said:


> Don't we resuscitate after the pt codes? And we stop after declaration?



Depends on your hospital and EMS system setup. Yes we declare after the patient is dead...most of the time....but our hospital also calls "code blues" and our EMS crews do as well (we use triage colors for general impression on the radio) for patients in respiratory arrest with a high probability of imminent arrest. We consider this resuscitation of a patient from near death I guess.


----------



## usalsfyre (Dec 27, 2013)

Texas uses DNRs/DNIs. The legal wording spells out that artificial ventilations (even to assist a patient still breathing) is considered "life prolonging" and therefore verboten.


----------



## TheLocalMedic (Dec 27, 2013)

Epi-do said:


> I am not going to comment about treatment of this patient, since everyone else has pretty much covered that angle.
> 
> The point that I want to make is that you stated this is a DNR and the patient is in respiratory _distress_.  Therefore, I am going to assume they still have a respiratory drive and a pulse.  Since a DNR only covers what is to be done in the event of a resuscitation, it isn't even in play at this point.  I know it gets said all the time, but Do Not Resuscitate does not mean Do Not Treat.  Do what is best for this patient to assist in improving his/her respiratory status.



You stole my response!  DNR comes into play once they are in cardiac or respiratory arrest.  Until they reach that point, it's treatment as you would for anyone else.  Yes, even patients in resp failure get a BVM.  Once they completely stop breathing, then you can follow the DNR wishes.  

This is why the DNR is many areas is being replaced by different forms.  Here it's the POLST; Physician's Orders for Life Sustaining Treatment) which goes into much more detail about what a patient does or does not want done.


----------



## usalsfyre (Dec 27, 2013)

TheLocalMedic said:


> You stole my response!  DNR comes into play once they are in cardiac or respiratory arrest.  Until they reach that point, it's treatment as you would for anyone else.  Yes, even patients in resp failure get a BVM.  Once they completely stop breathing, then you can follow the DNR wishes.



Ummm...again, not in the state of Texas.


----------



## TheLocalMedic (Dec 27, 2013)

usalsfyre said:


> Ummm...again, not in the state of Texas.



I suppose it's a matter of interpretation based on the situation though.  Sure, if someone is circling the drain because they're simply dying and have a DNR in place, I wouldn't ventilate them.  But how many times have you seen people on Hospice care who have DNRs in place who experience a sudden acute illness that they want treatment for?  Like a guy dying from liver failure experiencing an severe allergic reaction (happened to me).  I would, and did, absolutely treat that acute illness with everything I had, including giving epi and assisting his breathing with a BVM and in-line neb.  They guy was planning on going out, but not like that.  He improved quickly and was grateful that we helped him.


----------



## TransportJockey (Dec 27, 2013)

usalsfyre said:


> Texas uses DNRs/DNIs. The legal wording spells out that artificial ventilations (even to assist a patient still breathing) is considered "life prolonging" and therefore verboten.



NM EMS DNRs are worded the same way


----------



## jwk (Dec 27, 2013)

I think every state has a "living will" and/or advanced directive statute.  A living will is an advanced directive from the patient.  That statute is usually pretty specific, and frequently gives the wording used in the form that is signed by the patient.  Closely related and frequently completed at the same time are the Durable Power of Attorney for Healthcare, giving a specific person or persons the right to act if the patient cannot.  Every hospital is supposed to ask every patient if they have one, and if they don't, would they like to have one?  Those forms are very specific on what is and is not appropriate and what treatment may or may not be given to the patient.  Patients already in hospice care should have one available.    

A DNR and living will are NOT the same thing.  A DNR order is an order from a physician, mainly used in a hospital, but I'm assuming would also be found in nursing homes.


----------



## broken stretcher (Dec 28, 2013)

Is the pt conscious? Then the DNR doesn't matter until this changes.


----------



## Rialaigh (Dec 28, 2013)

broken stretcher said:


> Is the pt conscious? Then the DNR doesn't matter until this changes.



It does matter, we are supposed to be patient advocates and doing what the patient wants or would want done to and for them. This all or nothing approach in EMS is absurd and really shows a lack of critical thinking and ability to make judgement calls. I am treating a treating a 45 year old respiratory failure with no DNR differently from a 98 year old respiratory failure with a DNR, even if both of them are conscious. I don't just throw the protocol book at everyone who is still breathing because I can.

In most cases patients in the elderly age group do not want every treatment you can throw at them even if they aren't DNR's. And before someone jumps in and says that's not our decision...it absolutely is. In my humble opinion treating someone more than they would want knowingly (even in an impaired patient) is just as bad as withholding treatment. In cases where it isn't black and white there is often quite a bit of evidence of what a person wants done or doesn't want done. It shouldn't be a "do everything unless the patient is alert and oriented". It should be a "The patient isn't alert and oriented...based on the findings and other people I have on scene what do I think this patient would want done".

Be a patient advocate, do what you think the patient would want.


----------



## mycrofft (Dec 28, 2013)

If a patient decides not to follow through on a DNR and demands care, you give it. IF they then lose consciousness, the latter decision, if competent, is followed. It's like a codacil on a will.

I'm cheered to see no one used the old "just wait until they lose consciousness" dodge.

Resp distrees versus failure:

Distress: I can't breath properly.
Failure: I can't breathe effectively at all.
Distress is a possible sign of impending failure. Failure is a sure sign of impending death.

Clinical signs, and not just semantics until we're comfy at our keyboards.


----------



## Akulahawk (Dec 28, 2013)

broken stretcher said:


> Is the pt conscious? Then the DNR doesn't matter until this changes.


It matters a LOT! IF my DNR patient is actually conscious, then the patient has the ability to request that I ignore the DNR or they can agree to a specific treatment plan that I propose that ignores the DNR. If the patient is not conscious, then I can only go by what's stated in the DNR and my protocols about said DNR.


----------



## TheLocalMedic (Dec 29, 2013)

Rialaigh said:


> It does matter, we are supposed to be patient advocates and doing what the patient wants or would want done to and for them. This all or nothing approach in EMS is absurd and really shows a lack of critical thinking and ability to make judgement calls. I am treating a treating a 45 year old respiratory failure with no DNR differently from a 98 year old respiratory failure with a DNR, even if both of them are conscious. I don't just throw the protocol book at everyone who is still breathing because I can.
> 
> In most cases patients in the elderly age group do not want every treatment you can throw at them even if they aren't DNR's. And before someone jumps in and says that's not our decision...it absolutely is. /QUOTE]
> 
> This is a dangerous line of thinking, in my opinion.  You can't assume that just because a patient is old or someone is impaired that they don't want treatment.  They may have a DNR, but that isn't the same as wanting to die.  You have to assume that they want to live, and then follow the DNR wishes if they actually tank.


----------



## Hunter (Dec 29, 2013)

Maybe I miss it but what we're his lung sounds, everyone accessing cpap but that won't help in asthma.


----------



## Wheel (Dec 29, 2013)

Hunter said:


> Maybe I miss it but what we're his lung sounds, everyone accessing cpap but that won't help in asthma.



CPAP can actually help greatly in asthma patients. It can decrease their work of breathing, help splint the airway, and can be used with inline nebs.


----------



## NomadicMedic (Dec 29, 2013)

Second. It's used with nebulized meds frequently. I believe prehospital CPAP is amazing and is the ONLY "ALS skill" that should be given to basics.


----------



## Akulahawk (Dec 30, 2013)

Hunter said:


> Maybe I miss it but what were his lung sounds,  everyone accessing cpap but that won't help in asthma.


Given that the OP was treating with Albuterol and Atrovent, we can only  take an educated guess that there was some kind of reactive airway  problem going on, probably asthma. Using a BVM is a very poor-man's way  to create a CPAP-like situation. Unless there's a very good mask fit _and_ there's a PEEP valve on it, a BVM isn't going to come anywhere close to being able to truly approximating a CPAP system. 

CPAP does apparently work a bit better than a NRB alone in these  patients in ensuring appropriate ventilation. These patients are  probably the #1 reason why CPAP was _finally_ approved for field  use by Paramedics. I would prefer to use CPAP with a mixed gas (such as  heliox) in these patients so that I can keep them from having to be  intubated and/or put on a vent because of the issues that go along with  being intubated and being on a vent. 

On top of it all, you can do in-line nebs of patients that are on a CPAP  and because of the pressure support, whatever's being nebulized should  reach further down the respiratory tract and have a greater effect than  it would otherwise.


----------



## TheLocalMedic (Dec 30, 2013)

All of the above…  or more succinctly:  Ditto


----------



## Akulahawk (Dec 30, 2013)

TheLocalMedic said:


> All of the above…  or more succinctly:  Ditto


IF anyone is into _really_ deep diving, you'll know what I mean about using heliox (or for that matter, a tri-mix). When going DEEP, there's both issues of partial pressures to deal with and atmospheres of just nitrogen and oxygen can get quite dense, though probably only our lungs would notice _that_ effect. Over the years, I've run across some RT's that were strong proponents of using mixed gasses in conjunction with CPAP for those very difficult to ventilate patients. IIRC, a hospital just south of me (St. Joseph's in Stockton) did their own study about 10-12 years ago and found that by using mixed gasses in this population, they were able to either keep patients off the vent entirely OR reduce the number of days on the vent by about 3 days, including weaning time. I no longer have a copy of their results handy (it's been that long) but their findings have stuck with me since. 

Oh, and thanks for the "ditto!"


----------



## Mark Lassman (Dec 30, 2013)

I USED TO have my EMT, but it’s been 10 years since I had to let it lapse due to work situation, but… I am in my 3rd year of law school, and wanted to chime in on this issue.

Normally, a “DNR” order means exactly that. If the patient, or their legal representative, has signed a valid DNR order, does that mean you can’t do ANYTHING to keep that patient alive, or does that mean you can, as has been suggested, used “passive” methods like a mask or cannula, but not “artificial” methods like a BVM, intubation, CPR, etc.?


----------



## unleashedfury (Dec 30, 2013)

DEmedic said:


> Second. It's used with nebulized meds frequently. I believe prehospital CPAP is amazing and is the ONLY "ALS skill" that should be given to basics.



In Pa its BLS skill for those who completed the training and the squads that are participating in the program. 

As a provider theres a 4 hour class you must take, Medical Director must approve it, and theres a whole QA process to participate in after the call is completed. Its proven to have its advantages as in some areas a ALS intercept may be 30 minutes away.


----------



## mycrofft (Dec 30, 2013)

Have we digested the inadvisability of bagging (resuscitating) someone with a DNR unless they say themselves to go ahead?


----------



## Carlos Danger (Dec 30, 2013)

mycrofft said:


> Have we digested the inadvisability of bagging (resuscitating) someone with a DNR unless they say themselves to go ahead?



There seems to be considerable regional variations in terminology. 

Where I was trained (NYS), a DNR does not kick in until the patient loses pulses and/or spontaneous respirations. Up until that point, you treat them just like every other patient, meaning assisting with ventilations and even intubating if indicated, along with pressors, blood, surgery, and other resuscitative measures.

If they don't want ventilation or intubation or pressors, then that requires a different type of advanced directive. A DNR itself does not apply until a respiratory or cardiac arrest has occurred.


----------



## Mark Lassman (Dec 30, 2013)

Generally speaking, you are probably correct in that a DNR “does not apply until a respiratory or cardiac arrest has occurred.”

However, there are also probably regional variations as to what constitutes a valid DNR request, and it is also possible that a DNR order could be “customized”, in that you can do THIS but you can’t do THAT.

I am only familiar (somewhat) with California law.


----------



## TheLocalMedic (Dec 31, 2013)

Regardless, assisting ventilation is a non-invasive procedure that can absolutely be used to treat respiratory distress, even if they have a DNR.  Throwing up your hands and saying, "Can't help you!  You've got a DNR!" is a big misunderstanding.  You should absolutely treat them up until that DNR kicks in:  when they quit breathing or lose a pulse.


----------



## mycrofft (Dec 31, 2013)

Halothane said:


> There seems to be considerable regional variations in terminology.
> 
> Where I was trained (NYS), a DNR does not kick in until the patient loses pulses and/or spontaneous respirations. Up until that point, you treat them just like every other patient, meaning assisting with ventilations and even intubating if indicated, along with pressors, blood, surgery, and other resuscitative measures.
> 
> If they don't want ventilation or intubation or pressors, then that requires a different type of advanced directive. A DNR itself does not apply until a respiratory or cardiac arrest has occurred.



A DNR stating you forbid resuscitation which only works once resuscitation has failed means either it's meaningless, or you suck   at resuscitation (maybe on purpose).


----------



## mycrofft (Dec 31, 2013)

TheLocalMedic said:


> Regardless, assisting ventilation is a non-invasive procedure that can absolutely be used to treat respiratory distress, even if they have a DNR.  Throwing up your hands and saying, "Can't help you!  You've got a DNR!" is a big misunderstanding.  You should absolutely treat them up until that DNR kicks in:  when they quit breathing or lose a pulse.



"Sir or Ma'am, would you like me to help you breathe?".

PS: anyone saying being BVM'ed isn't intrusive obviously hasn't had it done to them. Especially with that yummy canned oxygen.<_<


----------



## Mark Lassman (Jan 1, 2014)

That makes sense. Thank you.


----------



## JPINFV (Jan 1, 2014)

Resuscitation is not limited to patients in pulse-less situations, but any time an acutely life threatening event is present. The patient who was in septic shock and received pressures and fluids to stabilize his blood pressure has been resuscitated. If you are using a BVM on anybody who is not already vent dependent, you are engaged in a resuscitation.


----------



## Hunter (Jan 2, 2014)

JPINFV said:


> Resuscitation is not limited to patients in pulse-less situations, but any time an acutely life threatening event is present. The patient who was in septic shock and received pressures and fluids to stabilize his blood pressure has been resuscitated. If you are using a BVM on anybody who is not already vent dependent, you are engaged in a resuscitation.



By that logic though would you call a hypoglycemic shock patient who's received D50 a resuscitated patient? Would you withhold the D50?


----------



## Akulahawk (Jan 2, 2014)

Hunter said:


> By that logic though would you call a hypoglycemic shock patient who's received D50 a resuscitated patient? Would you withhold the D50?


Being that D50 provides calories to a patient, wouldn't simply feeding a patient be considered resuscitation, using the same logic?

My answer is no, I wouldn't normally withhold D50. It's not among the list of things I'm not allowed to do when presented a DNR. It may, however, not be something I'm allowed to provide if the patient's POLST forbids it.


----------



## Hunter (Jan 2, 2014)

akulahawk said:


> being that d50 provides calories to a patient, wouldn't simply feeding a patient be considered resuscitation, using the same logic?
> 
> My answer is no, i wouldn't normally withhold d50. It's not among the list of things i'm not allowed to do when presented a dnr. It may, however, not be something i'm allowed to provide if the patient's polst forbids it.



polst?


----------



## NomadicMedic (Jan 2, 2014)

POLST. Physician's orders for life sustaining treatment. It's become the accepted a la carte "DNR" form in many states.


----------



## JPINFV (Jan 2, 2014)

Hunter said:


> By that logic though would you call a hypoglycemic shock patient who's received D50 a resuscitated patient? Would you withhold the D50?



Yes...

...and yes if the DNR specifically mentioned no IV dextrose (or some sort of equivalent wording). I've yet to see anything close to that. In general DNRs are very specific about what is and what is not allowed and when they're in effect. 

On the other hand, the concept of "no artificial respiration if the patient doesn't have a pulse, but hey, there's a pulse so we're good" is absurd when presented with a DNR that says "no artificial respiration, period."


----------



## JPINFV (Jan 2, 2014)

DEmedic said:


> POLST. Physician's orders for life sustaining treatment. It's become the accepted a la carte "DNR" form in many states.




...which is why I consider them to be the same thing. Heck, even before POLSTs became popular, I've seen DNRs from some facilities spell out very specifically what the patient does or does not want, including things like antibiotics and hospitalization.


----------



## Rialaigh (Jan 2, 2014)

JPINFV said:


> Yes...
> 
> ...and yes if the DNR specifically mentioned no IV dextrose (or some sort of equivalent wording). I've yet to see anything close to that. In general DNRs are very specific about what is and what is not allowed and when they're in effect.
> 
> *On the other hand, the concept of "no artificial respiration if the patient doesn't have a pulse, but hey, there's a pulse so we're good" is absurd when presented with a DNR that says "no artificial respiration, period.*"




I'm glad someone else agrees here. I think the "all or nothing" mentality is one of the worst things left in EMS. I don't give every single trouble breathing patient a steroid...it's in the protocols but I choose to withhold it for various reasons...I use critical thinking and make a decision based on a;l the signs and symptoms other information presented to me. I do the same when presented with a DNR


----------

