# Time to Present a DNR?



## MJD1521 (Jan 15, 2009)

You arrive on the scene of an unresponsive, non-breathing to find just that - a 91 y/o female lying in her bed, cool to the touch, apneic, and pulseless.

The family member couldn't find the DNR right away and asks you to wait before you start resuscitation efforts so she can find the DNR.  What do you do?  Begin resuscitation efforts, wait a little while, or wait until she can find the DNR?


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## EMTCop86 (Jan 15, 2009)

MJD1521 said:


> You arrive on the scene of an unresponsive, non-breathing to find just that - a 91 y/o female lying in her bed, cool to the touch, apneic, and pulseless.
> 
> The family member couldn't find the DNR right away and asks you to wait before you start resuscitation efforts so she can find the DNR. What do you do? Begin resuscitation efforts, wait a little while, or wait until she can find the DNR?


 
I was just going over this is my text book. Depends on your state and local protocols but from my understanding you start working her until you see papers.


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## Sapphyre (Jan 15, 2009)

MJD1521 said:


> You arrive on the scene of an unresponsive, non-breathing to find just that - a 91 y/o female lying in her bed, cool to the touch, apneic, and pulseless.
> 
> The family member couldn't find the DNR right away and asks you to wait before you start resuscitation efforts so she can find the DNR.  What do you do?  Begin resuscitation efforts, wait a little while, or wait until she can find the DNR?



Cool, pulseless and apneic?  Sounds like she's probably been gone for a while.  First on, though, I have to work it until DNR is presented, or medics arrive and their protocols kick in.


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## JPINFV (Jan 15, 2009)

Current location:
Start resuscitation, contact med control.

Old location: If immediate family on scene is in agreement, have an immediate family member sign the run sheet attesting to the fact the immediate family member is requesting that we withhold resuscitation. Treat as any other DNR.


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## vquintessence (Jan 15, 2009)

Yeah, just initially do a half hearted approach to CPR while they fish it out.  Who knows if the entire family is in agreement about the DNR.  Just some CYA.


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## firecoins (Jan 15, 2009)

CPR until DNR is produced.  Than it can be called.


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## BossyCow (Jan 15, 2009)

Any lividity? When was the woman last seen by the family member as conscioius, minutes? hours? days? The big thing is the coolness. What is the temp in the house? Warm or cool? Is it hypothermia or death? If the room is warm and the body isn't, she's been gone for a bit. I don't like to do CPR on corpses, its creepy. 

I'd probably hook up a monitor and if I see asystole in 2 leads, I'd call MPD and the sheriff for in home death.


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## traumateam1 (Jan 15, 2009)

CPR and AED until an official DNR is presented to me. No DNR? Well, sorry.. can't take your word for it.

Of course if there is lividity, than well.. your not gonna start CPR. ANd like Bossy said, if the room is warm and the body isn't... well they've been like this for a while, time to call it.


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## Tincanfireman (Jan 15, 2009)

I'm with Bossy; "cool to the touch" is kind of subjective, but lividity and rigor (if present) are pretty darn objective indicators. Usually finding a clenched jaw when trying to open the airway is your first clue. In addition, has the patient/deceased been checked for s/s of lost functionality, i.e. defecation? Granted, absence of/presence of is not an absolute indicator, but it's certainly significant when added to other indicators.  In the spirit of the scenario, I'd call for ALS backup and advise what we had discovered so far. If I'm not certain the person is well and truly deceased, proceed per protocol without delay unless DNR papers are produced.


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## marineman (Jan 15, 2009)

BossyCow said:


> I don't like to do CPR on corpses, its creepy.



I've never done CPR on a living person so I don't have something to compare to. 

JPINFV, I've heard of similar orders to the old place you worked but when we were talking about it in class a question came up about what if it's an intentional poisoning or some form of homicide by the family? For that reason we leave the decision up to the med director. 

With the description given I'd check for rigor or other obvious signs that they're not coming back, then start working it until they show me papers. The whole cold part would potentially be a problem depending on the circumstances and what you consider cold. You're not dead until you're warm and dead.


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## JPINFV (Jan 15, 2009)

marineman said:


> JPINFV, I've heard of similar orders to the old place you worked but when we were talking about it in class a question came up about what if it's an intentional poisoning or some form of homicide by the family? For that reason we leave the decision up to the med director.


I fully support working up a call if something seems fishy. It's great, though, for home hospice patients who might not have a valid DNR. It makes everything more smoothly.


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## marineman (Jan 15, 2009)

yeah, it's a nice option to have available. The docs at the service I'm riding with will almost always go with the medics opinion because they have a reputation in the area for really knowing what they're doing.

The service I work for in Milwaukee is another story entirely.


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## Tincanfireman (Jan 15, 2009)

And lest I am accused of thead-jacking, I'll just say this; nothing is sadder than responding to a home for a pt in respiratory distress, then arriving on scene and find a (maybe) 80 lb female laying in bed. Family says she is not a hospice patient yet, but is a DNR secondary to CA that has metastisized everywhere. When we ask for the DNR paperwork, we are told it's "in the garage somewhere" because they had just moved Grandma to the daughter's residence and hadn't gone through the boxes yet. Thankfully, sitting her up and applying 4 LPM via N/C was all it took to bring her color back up. We transported per the family's request, and she did make it to the ER before I had to face the possibility of doing compressions of her frail little body. We did have a talk with the family regarding the importance of that envelope, and they were looking through the garage as we transported.


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## june125 (Jan 19, 2009)

when in doubt call medical controll and let them make the decision, the family does have some time to find it, you need to verify pulseless, rigor, lividity, apenic. If they dont have it by then and they dont want to to work on their relative, call a doctor. They usually (at least in my area) will ok you not working it.


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## A36 (Jan 22, 2009)

Tincanfireman said:


> And lest I am accused of thead-jacking, I'll just say this; nothing is sadder than responding to a home for a pt in respiratory distress, then arriving on scene and find a (maybe) 80 lb female laying in bed. Family says she is not a hospice patient yet, but is a DNR secondary to CA that has metastisized everywhere. When we ask for the DNR paperwork, we are told it's "in the garage somewhere" because they had just moved Grandma to the daughter's residence and hadn't gone through the boxes yet. Thankfully, sitting her up and applying 4 LPM via N/C was all it took to bring her color back up. We transported per the family's request, and she did make it to the ER before I had to face the possibility of doing compressions of her frail little body. We did have a talk with the family regarding the importance of that envelope, and they were looking through the garage as we transported.



I had the exact same type of patient who we were transporting to a hospice. Problem was the DNR was left at the hospital. Sure enough, she coded and we had no choice but to work her.

Long story short, the patient isn't a DNR without a DNR present and filled out completely and correctly.


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## Outbac1 (Jan 28, 2009)

Fortunatly here I don't need to see a DNR. If I am told there is one or family dosen't want cpr then I have no problem not starting. Document who said what and info on deceased, wait for police for an out of hosp death. Then back in service.


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## A36 (Jan 28, 2009)

Outbac1 said:


> Fortunatly here I don't need to see a DNR. If I am told there is one or family dosen't want cpr then I have no problem not starting. Document who said what and info on deceased, wait for police for an out of hosp death. Then back in service.



Wish I could've done the same. Unfortunately MA protocols on DNRs are pretty rigid. If they don't have a DNR and according to the protocols they should be worked, they get worked. Of course, then there's med control but that's another mess altogether.


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## redcrossemt (Jan 28, 2009)

A36 said:


> Wish I could've done the same. Unfortunately MA protocols on DNRs are pretty rigid. If they don't have a DNR and according to the protocols they should be worked, they get worked. Of course, then there's med control but that's another mess altogether.



What kind of mess? Your doctors would make you work an 80-year old 80-lbs. frail woman with terminal cancer and a family stating she's a DNR?


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## A36 (Jan 29, 2009)

redcrossemt said:


> What kind of mess? Your doctors would make you work an 80-year old 80-lbs. frail woman with terminal cancer and a family stating she's a DNR?



They would, they did, and I had to.


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## WFDJustin (Jan 29, 2009)

If they cant find/or dont have the DNR order in there possession then start CPR, notify your base hospital, and dont stop til you see that DNR order or a equal/higher trained ems personel take over patient contact. The worst they can do to you is attempt to file a lawsuit for performing CPR with a standing DNR that was not to be found anywhere at the time of incident. But think of it this way would you rather win a lawsuit against u for doing your job, or lose the lawsuit because you held off on CPR because the family *said* they had a DNR and then conveniently remember after the patients as good as pronounced that he/she didnt have a DNR after all. When in doubt follow your training.


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