# DNR and assisted ventilations.



## dacrowley (Jul 28, 2013)

I'm sure the answer is on here somewhere, but I searched and couldn't find it. So:

You've been called to the scene for 70yo male with irreversible kidney failure, due to the onset of pneumonia with associated DIB. Hospice nurse is on scene and is the one who called. Wife brings you a DNR for the patient. Pt is breathing 8-10 times a min with rales and wheezing bilaterally. 

Am I correct to assume that as long at this pt. is breathing on their own we can provide respiratory assistance with a BVM, but if they become apnic (but not pulseless) we must stop ventilations? Or do we continue ventilations until the patient become pulseless as well? :huh:

Thanks.


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## chaz90 (Jul 28, 2013)

Depends how the DNR is written, but most only go into effect when the patient is pulseless or apneic. If he has an advanced directive as well stating no "heroic measures," "no life support," or palliative care only, that would be a different scenario.

Now for my own curiosity, why did the hospice nurse call? What is she hoping will happen after your arrival?

Also, I kind of laughed at your DIB abbreviation. I'm sure you mean Difficulty in Breathing, but the term I use most often for that is SOB. To me, DIB is Dead in Bed


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## yowzer (Jul 28, 2013)

DNR does not mean Do Not Treat. Comfort measures like oxygen therapy would be appropriate. Ventilation, possibly. What does the wife want done?


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## dacrowley (Jul 28, 2013)

The hospice called for transport of the pt to hospital for treatment of the developing pneumonia. In this case the wife assumed us using a BVM to assist with ventilations as resuscitation attempts, even though he was breathing on his own with difficulty.

Lol... pneumonia with associated Dead In Bed... I can see why you chuckled. I used to use SOB, but I've come to understand that term isn't 'PC' anymore.


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## MSDeltaFlt (Jul 28, 2013)

Bare in mind that if they are on hospice and you transport, then the pt is discharged off of hospice which discontinues the DNR orders.  It also means that, should the pt recover to the point of discharge from hospital, they might not be allowed back on hospice, or at least with that hospice company.

Artificial ventilations, even BVM, is called "life support".  Keep that in mind when faced with a pt with valid DNR orders.

Also, changing level of care; hospice to hospital, outpatient to inpatient, ICU to floor, inpatient to home, discontinues all previous orders and they have to be rewritten.  Including DNR orders.

Need to varify with indigividual state.


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## Mariemt (Jul 28, 2013)

Slowed breathing and fluid in the lungs is not uncommon with the end of life. 8 to 10 breaths a minute? I would consider O2 for comfort measure and ask the nurse to call his doctor. If the patient is alert, the bvm is going to be uncomfortable to him.
If the patient is on morphine this isn't uncommon.
Bedridden patients develope fluid in the lungs.
I think it is best to ask was this causing pain to the patient? It is not our choice really to transport, but the patients. Does he want transport? Maybe consider calling ahead on this one. 
Why wouldn't the hospice nurse know these things?


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## JPINFV (Jul 28, 2013)

MSDeltaFlt said:


> Bare in mind that if they are on hospice and you transport, then the pt is discharged off of hospice which discontinues the DNR orders.  It also means that, should the pt recover to the point of discharge from hospital, they might not be allowed back on hospice, or at least with that hospice company.



Why would the hospice company discharge a patient because he was hospitalized for something that deserves hospitalization?

Why is the DNR dependent on hospice status? 




> Also, changing level of care; hospice to hospital, outpatient to inpatient, ICU to floor, inpatient to home, discontinues all previous orders and they have to be rewritten.  Including DNR orders.



While the medication orders at my hospital has to be rewritten when moving to/from ICU (which, in all honesty, is a form printed out from the electronic medical records), the DNR is still operative.


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## abckidsmom (Jul 29, 2013)

JPINFV said:


> Why would the hospice company discharge a patient because he was hospitalized for something that deserves hospitalization?
> 
> Why is the DNR dependent on hospice status?
> 
> ...



Yes, the DNR, especially an official form like VA's durable DNR, travels with the patient, at least under VA law. The family has a bright orange or yellow piece of paper that stays with the patient, in the chart, in the home, where ever. 

I would never feel comfortable providing positive pressure ventilation of any sort to someone at the end of life on hospice care. Not saying that I haven't participated in anxiety-driven melodrama on the part of the families, in hospital and out, that had end of life patients, but it's completely antithetical to what hospice is about. 

I would administer meds for comfort if the patient looked uncomfortable, but no on the BVM, and I really wouldn't want to use CPAP either, given a circumstance in which it was appropriate. 

Were it my personal loved one on hospice care, I doubt we would treat the pneumonia. Everybody dies. Prolonging the misery at the end can be dishonoring and unmerciful.


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## Clipper1 (Jul 29, 2013)

I think the problem here is some don't actually know what hospice is and automatically mean the patient should die.  Hospice is about improving the quality of life for the time left. This can include being treated for things which normally would not cause death.  For PNA, the patient can be ventilated by BIPAP and can also be intubated in the hospital to be treated. Their DNR will remain even while on the ventilator. It just means if their heart stops they will not be resuscitated.

When in doubt, call the patient's physician and/or your med control for advice.

Maybe some here should attend an inservice or get a rep from a hospice agency to give a lecture about the services they do provide.


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## Christopher (Jul 29, 2013)

MSDeltaFlt said:


> Bare in mind that if they are on hospice and you transport, then the pt is discharged off of hospice which discontinues the DNR orders.  It also means that, should the pt recover to the point of discharge from hospital, they might not be allowed back on hospice, or at least with that hospice company.
> ...
> Need to varify with individual state.



Not in NC. The DNR or MOST is valid, hospice or not. Hospice has no say in the patient's DNR/MOST status.

They may not take on a patient who lacks DNR/MOST status, but they certainly cannot revoke it.


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## Clipper1 (Jul 29, 2013)

Christopher said:


> Not in NC. The DNR or MOST is valid, hospice or not. Hospice has no say in the patient's DNR/MOST status.
> 
> They may not take on a patient who lacks DNR/MOST status, but they certainly cannot revoke it.



But, in this situation Hospice is not revoking the DNR. Requesting treatment is not revoking the DNR.  The patient's heart has not stopped.  PNA is treatible. The goal of Hospice is to decrease suffering and improve quality of life. Hospice does not mean the patient is going to die from their disease the same day or even in the next few months.  If this nurse denied the patient their right to treatment as explained in a Hospice admit process, that would be very wrong and grounds to take action against his or her license.


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## Christopher (Jul 29, 2013)

Clipper1 said:


> But, in this situation Hospice is not revoking the DNR. Requesting treatment is not revoking the DNR.  The patient's heart has not stopped.  PNA is treatible. The goal of Hospice is to decrease suffering and improve quality of life. Hospice does not mean the patient is going to die from their disease the same day or even in the next few months.  If this nurse denied the patient their right to treatment as explained in a Hospice admit process, that would be very wrong and grounds to take action against his or her license.



I wasn't commenting on that bit. I was commenting on the bit where MSDeltaFit stated hospice could "revoke" it. There is a difference between treating in spite of a valid DNR/MOST and "revoking" a valid DNR/MOST.

(I have no qualms with treating DNR/MOST patients, didn't know that was the issue I was addressing)


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## MSDeltaFlt (Jul 29, 2013)

As I said, verify with your state.


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## Rialaigh (Jul 29, 2013)

What does the wife want...that's what the patient gets, I would be very hesitant to use any manner of assisted ventilations unless the wife really wanted it, In which case I would be happy to oblige, if the wife wants O2, thats fine, if she adamantly does not want even a simple o2 mask or cannula and the patient is not begging for one either, that's fine too. I do as little as possible for this patient and basically anything the wife request. 

Best thing for this guy is a comfortable pillow, a blanket, and a ride to the hospital where the wife and the patient can speak with a physician to make more in depth end of life plans.


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## Clipper1 (Jul 29, 2013)

One of he big obstacles which keep some patients from entering a hospice program is the concern they are labeled as already dead and can not get treatment.  It is much the same as the DNR only worse. Many patients in SNFs will not sign a DNR nor will their families because they think all they'll get is a pillow and a corner to die in. This is why most Hospice nurses are involved in the planning and on going education of the patient and their family.  This education really needs to be extended to other caregivers such as EMTs and Paramedics.

If this is a new acute illness, it should be treated as such unless you plan on intubating. ANY concerns you have should be addressed with the physicians either your MD or the patient's. But, refrain from getting into a major "protocol" argument at the patient's bedside. Nothing worst then having a patient feel helpless if they don't "fit" your protocols. Every patient is in hospice for different reasons and some will have months to go before their terminal illness finally ends their life.

Fine out what the goal of the call is and treat accordingly. Put aside your negative feelings about "hospice nurses" and talk to them. They have a tough job also and will have to document their decision process very carefully. Hospice is supposed to be about quality of life be it pain free and comfortable or a hold over until a decision about more treatment is made. If a patient needs oxygen, please don't withhold it.  If the patient needs pain medications, see what they have been getting and give more as appropriate. This should not be a guilt trip to lay on the wife. Explain what you will do but please do not make it sound like this is going to be a burden of a decision. The whole process of watching someone you care about die is tough enough.  Often the Hospice RN is speaking for the family since he or she has be doing the education and carrying out the care plans which have been laid out by the family and the doctors. Talk to the Nurse, the patient and the family but first find out more about hospice and the process before being so judgmental about the treatment.


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## Mariemt (Jul 29, 2013)

If this is a bacterial or viral thing, by all means, he needs treatment. A bvm for assisting vents? No. That won't make the pt comfortable.
The doctor needs called. Likely the pt can be treated without being uprooted if he is in the final stages. 
Fluid in the lungs is very very common in later stages. 
However fever and pain is plenty of reason to treat. O2 will not shirt this pt whether his SATs are fine or not . This is a case where o2 can be applied for comfort.  

I'm getting tired and not making Much sense.

The nurse called, you are now the patients advocate. If he doesn't seem to want or tolerate transport, call the doctor or request nurse does. 
I know from experience they are less hesitant to call in an antibiotic or whatever in the late stage of life and would much rather let the pt rest at home if he or she so desires. Yes, I spent 24/7 with a hospice patient minus shower time . The doctors and nurses will do anything to keep patients at home and comfortable. Even sending people to get blood drawn.  Sending courioirs with meds etc. The only things that can't be don't here is an x ray


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## Carlos Danger (Jul 30, 2013)

DNR does not mean "do not treat", but typically hospice patients are nearing death and only want comfort measures. That's why they are in hospice. Most of them also have their wishes pretty clearly spelled out in their advance directive. 

Best thing to do here, as has been pointed out, is to talk to the wife about what the patient wants, if of course he can't communicate himself.

Probably the best thing for this patient is morphine. Enough to make him comfortable.


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## Clipper1 (Jul 30, 2013)

Having PNA which is not treated is not comfort. Many patients in hospice are not always "near death".  Some patients go to hospice and still receive dialysis. Some are on high flow oxygen devices (the real high flow devices and not a nonrebreather mask). Some continue to wear their home CPAP or BiPAP devices. Some may go into the hospital for surgical procedures. Some may continue to talk about new treatments with their doctors. Some may go on rescue BIPAP in the hospital with a DNR. Some may be intubated with a ventilator and still have their DNR.

Being an advocate does not mean believing hospice equals imminent death.  Be careful there because with holding treatment may also put you crossing the line to cause the death along with unnecessary suffering.


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## Carlos Danger (Jul 30, 2013)

Clipper1 said:


> Having PNA which is not treated is not comfort.



With enough morphine it can be pretty comfortable, if that is what the patient wants.




Clipper1 said:


> Being an advocate does not mean believing hospice equals imminent death.
> 
> Be careful there because with holding treatment may also put you crossing the line to cause the death along with unnecessary suffering.



Which is exactly why I wrote:


Halothane said:


> Best thing to do here, as has been pointed out, is to *talk to the wife about what the patient wants*, if of course he can't communicate himself.



and



Halothane said:


> Most of them also have *their wishes pretty clearly spelled out in their advance directive*.



I said nothing about witholding treatment, or that hospice necessarily means that death is imminent.


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## Mariemt (Jul 30, 2013)

Clipper1 said:


> Having PNA which is not treated is not comfort. Many patients in hospice are not always "near death".  Some patients go to hospice and still receive dialysis. Some are on high flow oxygen devices (the real high flow devices and not a nonrebreather mask). Some continue to wear their home CPAP or BiPAP devices. Some may go into the hospital for surgical procedures. Some may continue to talk about new treatments with their doctors. Some may go on rescue BIPAP in the hospital with a DNR. Some may be intubated with a ventilator and still have their DNR.
> 
> Being an advocate does not mean believing hospice equals imminent death.  Be careful there because with holding treatment may also put you crossing the line to cause the death along with unnecessary suffering.


Nobody is talking about with holding treatment, only doing what the patient wants and keeping them comfortable. I said to advocate for the pt, no kill them. Why do you not pay attention?

Believe me. I know all about hospice,  unfortunately . More than most.
Believe it or not, it does mean the end is near, the patient and the doctor have usually decided the patient has less than 6bmonths.


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## Clipper1 (Jul 30, 2013)

Mariemt said:


> Nobody is talking about with holding treatment, only doing what the patient wants and keeping them comfortable. I said to advocate for the pt, no kill them. Why do you not pay attention?
> 
> Believe me. I know all about hospice,  unfortunately . More than most.
> Believe it or not, it does mean the end is near, the patient and the doctor have usually decided the patient has less than 6bmonths.


Reread some of the other posts.  There are many more posts here and not just yours. I also did not quote yours so what are you doing with this personal attack.

You might know about your own personal experience for a hospice pt but that is not how all hospice pt are managed. Did you know there is even ltc housing for hospice patients who might live up to a year or more?  Those of us who do work with hospice want both quality and comfort.  Every patient is different.  If you are in Washington I could have taken care of someone you know especially if it involed a child.  If you were not happy wiyh the care you should have had the opportunity to talk to the RNs and doctor.


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## Mariemt (Jul 30, 2013)

Clipper1 said:


> Reread some of the other posts.  There are many more posts here and not just yours. I also did not quote yours so what are you doing with this personal attack.
> 
> You might know about your own personal experience for a hospice pt but that is not how all hospice pt are managed. Did you know there is even ltc housing for hospice patients who might live up to a year or more?  Those of us who do work with hospice want both quality and comfort.  Every patient is different.  If you are in Washington I could have taken care of someone you know especially if it involed a child.  If you were not happy wiyh the care you should have had the opportunity to talk to the RNs and doctor.


I was the only one who said advocate, when you used that in the sense you did,  I knew that part was directed back at me. And if you think that was a personal attack I'd hate to see what a real one would do to you. I am not going to personally attack anyone. Good grief 
Yes I know there are housing for hospice
Where did I say at all I was unhappy with the hospice services? They were fantastic. It was unfortunate like many others I had to lose someone so close to me.


If the patient that this thread is about had more than a year, from the condition listed, I'm thinking him or his wife would have driven him to the doctor. A nurse wouldn't have had to call. 
That's why I believe he is coning to the end of life.

Most,  MOST of the time, hospice is for people who have less than six months, who have excepted they will die and do not plan to per sue heroic  Measures etc etc. They do standard treatments for comfort. However no chemo, radiations etc etc.  They do still take antibiotics as needed  high blood pressure meds, typical meds that improve the quality of their life.

Some people have gone off hospice care. Later to go back on. They had decided to fight their disease with new treatments,  or even their outlook was better and they were defying odds. 
Your state is obviously different.

But I never once said I was unhappy with the care. Don't put words in my mouth


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## JPINFV (Jul 30, 2013)

Clipper1 said:


> Having PNA which is not treated is not comfort. Many patients in hospice are not always "near death".


To be fair, they are supposed to be within 6 months of death to qualify for Medicare hospice specifically.

http://www.medicare.gov/Pubs/pdf/02154.pdf   Page 4.


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## savemachine (Aug 7, 2013)

*Dnr*



dacrowley said:


> I'm sure the answer is on here somewhere, but I searched and couldn't find it. So:
> 
> You've been called to the scene for 70yo male with irreversible kidney failure, due to the onset of pneumonia with associated DIB. Hospice nurse is on scene and is the one who called. Wife brings you a DNR for the patient. Pt is breathing 8-10 times a min with rales and wheezing bilaterally.
> 
> ...



DNR is do not resuscitate. Looks like in this situation it is just treatment, not resuscitation.


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## Clipper1 (Aug 7, 2013)

JPINFV said:


> To be fair, they are supposed to be within 6 months of death to qualify for Medicare hospice specifically.
> 
> http://www.medicare.gov/Pubs/pdf/02154.pdf   Page 4.





Not every patient is coveted by Medicare.  There are also private foundations which support Hospice services.


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## Einstein (Aug 9, 2013)

*Dnr*

wow
im amazed

the answer to the question is simple

dnr means "do not resuscitate"....not "do not withhold care"

if theyre pulsless aned apneic then can withhold

if not then you MUST assist their ventilations 

if they have advanced directive, stating no ventilation thats different

but if not you will  be killoing the patient

nurses call for medics with hospice patients with sob and dnrs because theyre not in arrest.  they may do well for years, and have bouts of sob.....that doesnt mean its your day to kill them


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## Aidey (Aug 9, 2013)

freepratique said:


> wow
> im amazed
> 
> the answer to the question is simple
> ...



Not a DNRs are that simple. Many states use POLST forms and depending on what options are selected on the POLST form assisted ventilations may not be ok, even in a patient that still has a pulse.


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## Einstein (Aug 9, 2013)

*dnr*

i love the comment about beating people on back boards......


i say hell-to-the-yeah!!!

rotflol


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## JPINFV (Aug 9, 2013)

freepratique said:


> wow
> im amazed
> 
> the answer to the question is simple
> ...





Except... it doesn't work that way. When the patient declines via advanced directive mechanical ventilation, then they decline mechanical ventilation. It's not a "Well, we can intubate them, and throw them on a vent as long as they're the ones triggering the vent."


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## Einstein (Aug 9, 2013)

Hmmmm

If they are dn"R" then it's dn"R"

We can debate foreger If they had a poorly thought out advanced directive etc or none, etc etc etc

But the question was, do you ASSIST a pt w/sob that has DNR?

In most states (at least mine)(lol) you MUST (as in duty to act) (and maybe even under implied consent) can't do nothing wen yur called to assist and the pt ain't dead

Advanced directive etc is a whole separate debate


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## Aidey (Aug 9, 2013)

It isn't a different debate. My state uses the POLST form. If they are having SOB and have selected palliative care I am not allowed to intubate or assist their ventilations in any way, including CPAP. I can give them oxygen and inhaled medications. But no ventilatory assistance, period. 

People have a right to refuse certain types of care, and a right to die. DNRs/advanced directives/POLST forms are ways of revoking consent to certain procedures. Your "duty to act" does not over rule those.


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## TransportJockey (Aug 9, 2013)

Here in nm an EMS DNR does not allow anything but palliative care. No CPR, assisted ventilations, advanced airways, electricity, etc.


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## Einstein (Aug 9, 2013)

*dnr*

HMMM

I should look up or ask you to remind me what POLSTB means in your state.  ...

I personally dont know what state yur in, but

We were talking about DNR.  not POLST.  if your state uses polst, and that polst allows for no cpr/bvm but everything else, then thats a DNR.

dnr means do not resuscitate.  assisting breathing is palliative and mandatory UNLESS THEY STATE otherwise.  assisting ventilation is ASSISTING not resusitating.  thats why there are spelled differently. ventilating someone where there is no natural ventilation is resusitating.


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## chaz90 (Aug 9, 2013)

freepratique said:


> HMMM
> 
> I should look up or ask you to remind me what POLSTB means in your state.  ...
> 
> ...



You're vastly over simplifying this issue. Under some circumstances and DNRs, ventilations are considered invasive life support and are not to be provided to patients with a DNR. As we've told you, this isn't universal.


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## Akulahawk (Aug 9, 2013)

freepratique said:


> HMMM
> 
> I should look up or ask you to remind me what POLSTB means in your state.  ...
> 
> ...


A DNR in California means the following:


No chest compressions
No assisted ventilation (No BVM, no vent, CPAP is OK)
No endotracheal intubation
No defibrillation
No cardiotonic drugs
As long as what you do does NOT fit the above things, then you're good to go. The patient does NOT have to be in an arrest situation before the DNR applies. Assisting ventilation IS resuscitation because you're forcing the person to breathe mechanically. CPAP just supplies pressurized air, the patient does the work of breathing. All the work. The patient can get antibiotics, tube feeding, IV nutrition, IV fluids (as long as it's not for resuscitation purposes), and so on. 


A POLST form is _much_ more specific about the allowed treatment. If the patient wants CPR done, they also request full measures as well, but they can select no tube feeding. 


The other difference between the two forms is that a Prehospital DNR is only valid outside the hospital, even though hospitals are encouraged to honor it. The POLST is valid everywhere and follows the patient.

_Other states may have different definitions from California, know your state's rules and follow those. _


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## Einstein (Aug 9, 2013)

I appreciate the banter, as i usually dont blog or posty or whatever im doing

i shud do this more often.  i just learned about NM protocol.

But guys, im not over simplifying:  Think about what youre saying.....So youre called to a street outside in an industrial area to find a 62 year old healthy, athletic looking Fire dept captain off duty whos gotm a bit of JVD, 02sat is poor and dropping, what appear to be rales....could be rales andf wheezes....has every sign of respiratory distress, and has a DNR bracelet and no other Hx Meds or NKDA.  

Youre not going to do anything?  

Seriously: Did this guy have toxic inhalation?  CHF?  Anneurism? Preexisting cardiac issues?  asthma?   exacerbation of some gasteroenterologic issue or rupture?  PE?  

Maybe the dnr bracelet worn "just in case" because after 28 years in Los Angeles Fire this guy's seen everything and doesnt want to be left vegetative after catastrophic trauma resulting in resuscitated arrest?  

YOU DONT KNOW.

Secenario 2
Old person with cancer end stage, with COPD, asthma, siezure disorder, lupus and hx of dialysis who in 9 months WILL want to go naturally, BUT TODAY is only having sever asthma attack?

DNR and POLST and advanced directive should be what they are; highly specific.  What does the state of NM expect you to do under the above situations?  Just let the guy gasp and die on the sidewalk b/c he has a DNR.  Remeber the debate was CAN YOU ASSIST VENTILLATIONS on a DNR.  and the answer is in the name:  do nor resuscitate.  that means DO NOT bring back from dead. 

However, OBVIOUSLY if a polst says no vent assist on a dnr.....then your choices are simple: either dont assist, break the law and assist, or become a EMS policy maker and change ridiculous law that says NO ASSIST for the guys in the above scenario


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## TransportJockey (Aug 9, 2013)

freepratique said:


> I appreciate the banter, as i usually dont blog or posty or whatever im doing
> 
> i shud do this more often.  i just learned about NM protocol.
> 
> ...



I'm curious about what part of 'no artificial ventilations' is not clear?  
Patient one would get CPAP and the full press short of intubation and ventilations. 
Patient two would get meds (IM Epi is allowable as its a different route and concentration than what it used for an arrest) and full protocol including CPAP. Up to and excluding intubation and ventilations. 

EMS DNRs are revocable by the patient or their designee, however. Although if I had a dnr and my family revoked it, they will be meeting me in hell, because I'll kill them where they stand.


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## JPINFV (Aug 9, 2013)

freepratique said:


> I appreciate the banter, as i usually dont blog or posty or whatever im doing
> 
> i shud do this more often.  i just learned about NM protocol.
> 
> ...



If only there was a way to treat that that didn't involve intubation. Oh, wait...



> Maybe the dnr bracelet worn "just in case" because after 28 years in Los Angeles Fire this guy's seen everything and doesnt want to be left vegetative after catastrophic trauma resulting in resuscitated arrest?
> 
> YOU DONT KNOW.



So, because we're not BFFs with the patient, we just ignore the DNR bracelet because, heck, maybe it's a fashion accessory?


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## Wheel (Aug 9, 2013)

freepratique said:


> However, OBVIOUSLY if a polst says no vent assist on a dnr.....then your choices are simple: either dont assist, break the law and assist, or become a EMS policy maker and change ridiculous law that says NO ASSIST for the guys in the above scenario



It's a "ridiculous law" that says a patient can put that they want no artificial ventilations in a POLST? How come you get to make their care decisions for them? As you said you don't know their reasons for having that.

Plus, no EMS policy maker is going to make care decisions for any patient. They have a right to refuse any treatment at any time.


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## Einstein (Aug 9, 2013)

no
its quite simple
do not resuscitate means if im dead (pulseless apenic) do not vent and no cpr or drugs

advance directive and polst covers no cpr or drugs, but if i just need vent, then ok.  or cpr and vent ok, but no drugs. etc...

I dont understand why you make the leaps of logic that you do, no offense.  I mean, no cheeseburger doesnt mean no hamburger.  it means no hamburger with cheese.

so in my scenario, why would you do anything if he has a DNR?  some of you said youd do everything but assist vent or et? some of you said nothing because of the dnr.   see the problem here???

we dont have the choice.  if hes dead with dnr we cant bring him back.  Period.  if hes not dead then we obligated to do all we can UNLESS HE HAS SPECIFIC INSTRUCTIONS ON HIS POLST what to do and what not to do.  

period. end of concept.

its no accident there is such a thing as "DNR" and another separate words called "advance directive"?  cow is cow, not cow might mean dog.  different words mean differnt things.  thats why we have an alphabet.  so do not dnr patients with asthma get treatment while those in arrest dont.  

can anyone give me a logical explanation why youd take someone whos not dead and apply a DO NOT RESUSCITATE to them.  they dont need resuscitation.......theyre alive.


if in your state there is only a polst and that covers dnr, or other specific things, then you must follow that.  but if your state has a polst, and on it theres a box labeled DNR as one of many boxes and that is the only box the patient checked, then it must be followed.

heres the scary part:  this is just my opinion.  im  not a lawyer.  im not a beurocrat.  im a retired firefighter paramedic who actually taught at a major university.  and thats what we taught!!! (cuz it makes sense...or at least it did a few years ago)


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## JPINFV (Aug 9, 2013)

freepratique said:


> heres the scary part:  this is just my opinion.  im  not a lawyer.  im not a beurocrat.  im a retired firefighter paramedic who actually taught at a major university.  and thats what we taught!!! (cuz it makes sense...or at least it did a few years ago)



Major university? So... UCLA? You do realize that UCLA's paramedic school doesn't count as being UCLA, right?


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## DesertMedic66 (Aug 9, 2013)

This may help clear up some confusion for California (it has kind of already been posted)



> EMSA/CMA APPROVED PREHOSPITAL DNR FORM
> 1. Under the EMSA/CMA approved Prehospital DNR Form, do not resuscitate (DNR) means no chest compressions, defibrillation, endotracheal intubation, assisted ventilation, or cardiotonic drugs.
> 2. The patient should receive all other care not identified above for all other medical conditions according to local protocols.





> EMSA APPROVED POLST FORM
> EMS personnel who encounter the EMSA approved POLST form in the field should be aware of the different levels of care in Sections A and B of the form (Section C does NOT apply to EMS personnel).
> Section A applies only to individuals who do NOT have a pulse and are NOT breathing upon arrival of EMS personnel.
> If an individual has checked “Attempt Resuscitation/CPR”, then EMS personnel should treat the individual to the fullest extent possible according to local protocols regardless of what may be checked in Section B.  For this individual this form as filled out does NOT constitute a DNR.
> ...



Source: http://www.emsa.ca.gov/pubs/default.asp#EMSA111
Section EMSA #111


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## Akulahawk (Aug 9, 2013)

While you're referring to NM, I'm going to answer from California's perspective. My answers to you will be inline and in red. 


freepratique said:


> I appreciate the banter, as i usually dont blog or posty or whatever im doing
> 
> i shud do this more often.  i just learned about NM protocol.
> 
> ...


Good discussion, but unfortunately many of us have a better understanding of the complexities of DNR/POLST than you do. There are aspects about those things that we don't like because we're normally quite DRIVEN to try to bring back the dying. We must think about what we do, and not emote our way through it.


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## Akulahawk (Aug 9, 2013)

More comments in red for you. 





freepratique said:


> no
> its quite simple
> do not resuscitate means if im dead (pulseless apenic) do not vent and no cpr or drugs and no electricity.
> 
> ...


It doesn't matter to me whether you are a retired FF/P that taught at a major university or not. It's obvious that you don't understand this topic sufficiently well.


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## Rialaigh (Aug 10, 2013)

I think most people are way overshooting here. 

Any scene I pull up that involves any questionable treatment of a DNR patient will involve the following.

Assuming the patient is conscious, they will get whatever treatment THEY WANT. I will not in any way shape or form try to force or place treatment on them that they do not specifically want. Treatment will be offered, they will decide, there will be no calling medical control or a supervisor or whoever else to try and convince them of the treatment. By all means if your a DNR and you don't want to wear a nasal cannula, power to you. 

If your having trouble making decisions or your somewhat incapable of making decisions and your spouse is on scene. It is very likely that my treatment will almost mimic whatever the spouse wants done (as long as the spouse verbalizes that he/she is acting in the interest of the DNR party). 


Point being most DNR decisions are not about what your legally ABLE to do, it is about being comfortable respecting a decision from either the patient or a spouse or medical power of attorney making decisions on behalf of the patient. 


If someone is having a ton of trouble breathing, is semi conscious and unable to make a decision for themselves, and presents with a spouse who has a DNR for them and the spouse says they would not have wanted any O2 or breathing assistance, I have to make a decision based on what I think the patient wants, and given the information I have there is nothing that leads me to believe the patient wants to be bagged, only information leading me to believe the patient would NOT want to be bagged, you have to  be comfortable making that distinction and that decision.


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## Einstein (Aug 10, 2013)

Ok then
Tell me where I don't understand

If the patient is alive what does a DNR have to do with this?

You tell me I clearly don't understand, then you articulate........

Why would a do not RESUSCITATE be relavent to a LIVE person?


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## DesertMedic66 (Aug 10, 2013)

freepratique said:


> Ok then
> Tell me where I don't understand
> 
> If the patient is alive what does a DNR have to do with this?
> ...



If that live person stops breathing or looses a pulse.


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## Einstein (Aug 10, 2013)

And btw
This is my first time or two posting.....don't get nasty and say I clearly don't know wat I'm saying......

Re my experience 
First of all I was being humble

Secondly
I've met many paramedics that I think were better than I and they were raised and schooled in Podunk nowhere.  So don't be so quick to judge 

Lastly It would be just as easy for me to say experience has PROVEN to be clinically sound in a university ER evironmemt sometimes surrounded by (and watching with great curiosity) leading cardiologists having lively debates, etc

I didn't get signed off by some preceptor (thank you I'm done now like so many barely competent medics across America....maybe you) 

I was greatfull and honored and humbled and fascinated by lecturers and leaders in their field on a regular basis.  If you were at all perceptive you'd have read what I said and seen I'm still humbled and amazed at the power we are given

But enough of that......
Where's your answer: WHY RESUSCITATION ORDER BE RELAVENT TO A LIVE PERSON? 

You also never answered the question I posed about the hospice patient with cancer end stage, with COPD, asthma, siezure disorder, lupus and hx of dialysis who in 9 months WILL want to go naturally, BUT TODAY is only having sever asthma attack......

Wats the answer to that?  You withhold tx?


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## Aidey (Aug 10, 2013)

Are you being deliberately obtuse? I think we have all made ourselves incredibly clear on this issue. The pt would be treated but not resuscitated. If they stop breathing, assisting their ventilations IS resuscitation, unless otherwise specified in the DNR paperwork. What is so hard about this for you to understand?

Also, to enroll in most hospice programs the pt has to have a life expectancy of 6 months or less.


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## VFlutter (Aug 10, 2013)

JPINFV said:


> Major university? So... UCLA? You do realize that UCLA's paramedic school doesn't count as being UCLA, right?



My EMT certificate, from a university affiliated program, looks just like my college Diploma h34r:




freepratique said:


> And btw
> This is my first time or two posting.....don't get nasty and say I clearly don't know wat I'm saying......



Welcome to the Thunderdome, I mean EMTlife. 



freepratique said:


> Re my experience
> First of all I was being humble



I am sure you were. 



freepratique said:


> Lastly It would be just as easy for me to say experience has PROVEN to  be clinically sound in a university ER evironmemt sometimes surrounded  by (and watching with great curiosity) leading cardiologists having  lively debates, etc


 
You keep mentioning "University" like it is supposed to impress us. How does being surround by and watching "leading" Doctors give you any credibility? 

My college was affiliated with one of the best Medical schools in the country. I did all my clinicals at one of the best hospitals in the country alongside prestigious medical professionals. Can I have a cookie? This does not add anything to my argument.  



freepratique said:


> I didn't get signed off by some preceptor (thank you I'm done now like  so many barely competent medics across America....maybe you)



Ok? Almost every Medical profession has some type of preceptorship for new graduates. Were you just born a competent medic? 




freepratique said:


> You also never answered the question I posed about the *hospice* patient  with cancer end stage, with COPD, asthma, siezure disorder, lupus and hx  of dialysis who in 9 months WILL want to go naturally, BUT TODAY is  only having sever asthma attack......
> 
> Wats the answer to that?  You withhold tx?



If this patient is a *hospice *patient then yes you withhold treatment. Hospice is comfort measures only and absolutely no life prolonging treatments. 

Not all patients with a DNR are on hospice. All patients on hospice will have a DNR. 

DNR does not mean Do Not Treat. Of course you would give nebs, 02, etc.


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## Einstein (Aug 10, 2013)

wow
A: not being obtuse.  read every entry.  Ive said someone breathing and circling the drain gets treatment despite DNR, while OTHERS have said breathing with DNR aint allowed.  THATS BEEN THE DEBATE.

But moving on, 
I mean you've got to be kidding me:
you just wrote, "If they stop breathing, assisting their ventilations IS resuscitation"...........

wow
Thats heavy.  
NO!!!  Assisting ventilations means ASSISTING someone.  You know, like PEEP.  As in CPAP being a form of assisted ventilation.  People who've stopped breathing are apneic and you arent assisting them.  YOU ARE ALONE VENTILATING them.  When you are BAGGING a patient in vfib you arent assisting ventilation.

re: 
Also, to enroll in most hospice programs the pt has to have a life expectancy of 6 months or less. 

.....I either did not know or forgot that.  Thank you


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## Aidey (Aug 10, 2013)

freepratique said:


> wow
> A: not being obtuse.  read every entry.  Ive said someone breathing and circling the drain gets treatment despite DNR, while OTHERS have said breathing with DNR aint allowed.  THATS BEEN THE DEBATE.
> 
> But moving on,
> ...



Now you're just being pedantic. 

People have made it incredibly clear that what treatment is and isn't allowed when a patient has a DNR varies by location and the exact wording on the DNR. You will not get a consensus on this because of those variations.


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## Handsome Robb (Aug 10, 2013)

freepratique said:


> wow
> A: not being obtuse.  read every entry.  Ive said someone breathing and circling the drain gets treatment despite DNR, while OTHERS have said breathing with DNR aint allowed.  THATS BEEN THE DEBATE.
> 
> But moving on,
> ...



You're obviously not nearly as competent as you think.

CPAP is not assisted ventilations. 

Assisted ventilations are a temporizing measure until the patient can be intubated, thus resuscitation. You lose, go straight to jail, do not pass go, do not collect 200 dollars. 

I graduated from a program affiliated with a University and its med school...can I have a cookie too? Or at least half of Chase's?


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## Einstein (Aug 10, 2013)

regarding whoever said i was being pedantic

i saw that word on family guy once....what an episode!!! HI-LARIOUS

I dont know what it means
but i do know this
this whole debate has been about do not RE\SUSCITATE someone who is still breating.  nothing more nothing less.

but if where this whole debate has lead is tantamount to the difference between withholding care on someone due to 

OK..I had to do it.  I looked up PEDANTIC

(a minute goes by)
wow
im gonna just sign off now.
by my last posting i think im proved that resuscitate menas BRING BACK not assist so they dont crash, 

i dont know what to say..............

if anyone out there thinks that witholding treatment on an asthmatic patient with a dnr is mincing words or splitting hairs or being pedantic, then 

A)
let me know what county you work in an ill make sure never to allow myself or loved ones to drive thru there,

B)
Id think long and hard about how many people I withheld from erroneously

AND 
C)
i think its time for you to say, like I have many times here, "hmmmm.....thanks, i did not know that." 

signing off and thanks for the banter.


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## Handsome Robb (Aug 10, 2013)

freepratique said:


> A)
> let me know what county you work in an ill make sure never to allow myself or loved ones to drive thru there,.



I was just gonna ask you this. Post it up so it's public knowledge because you are dangerous. 

I'd venture to say, based on your grammar, USE OF CAPITAL LETTERS, and lack of a intelligent argument you're still a probie. Or maybe even a white shirt!


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## chaz90 (Aug 10, 2013)

Well, this has been entertaining. Apparently some concepts I thought were easy to understand just aren't by some people. Goodbye freepratique. I hope (though I have my doubts) that you were able to learn something.


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## VFlutter (Aug 10, 2013)

freepratique said:


> A)
> let me know what county you work in an ill make sure never to allow myself or loved ones to drive thru there,



Ah how childish. I am glad you are retired, probably before I was even born, and no longer adding to the ignorance so rampant in EMS. 

You should hope you or your loved ones are lucky enough to be treated by one of our awesome forum members who are undoubtedly some of the best in EMS. 

And I like to think that I have allowed many patients their right to die with *dignity* on their own terms. That is something I would not dare take away.


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## DesertMedic66 (Aug 10, 2013)

freepratique said:


> regarding whoever said i was being pedantic
> 
> i saw that word on family guy once....what an episode!!! HI-LARIOUS
> 
> ...



Well I work in California (where you said you used to work).... I also quoted CA state DNR/POLST policy which answers most if not all your questions.


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## DesertMedic66 (Aug 10, 2013)

Chase said:


> Ah how childish. I am glad you are retired, probably before I was even born, and no longer adding to the ignorance so rampant in EMS.
> 
> You should hope you or your loved ones are lucky enough to be treated by one of our awesome forum members who are undoubtedly some of the best in EMS.
> 
> And I like to think that I have allowed many patients their right to die with *dignity* on their own terms. That is something I would not dare take away.









I feel like being a little childish hahaha


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## Einstein (Aug 10, 2013)

RE
And I like to think that I have allowed many patients their right to die with dignity on their own terms. That is something I would not dare take away.

I would like to think that too


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## Akulahawk (Aug 10, 2013)

freepratique said:


> Ok then
> Tell me where I don't understand
> 
> If the patient is alive what does a DNR have to do with this?
> ...


Resuscitate means to bring back. In this case, to bring back from death or impending death. So, a DNR patient who is in septic shock, but still alive, gets antibiotics and perhaps fluids, but not pressors to maintain BP. Why? Because pressors are cardiotonic. "Fluids" can be given PO or by IV. When the patient is circling the drain, and they've chosen to not be thrown a lifeline, it's their right to die.

Here's one for you: If your patient is clearly altered, has a heart rate of 22 and a BP that's barely palpable and is breathing 4 times a minute, are you going to start CPR? Are you going to hang dopamine or epinephrine, or put the patient on a pacer?This patient does have a valid DNR. This patient clearly isn't dead yet, so by your criteria, the patient is to be treated as full code...


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## Akulahawk (Aug 10, 2013)

Chase said:


> Ah how childish. I am glad you are retired, probably before I was even born, and no longer adding to the ignorance so rampant in EMS.
> 
> You should hope you or your loved ones are lucky enough to be treated by one of our awesome forum members who are undoubtedly some of the best in EMS.
> 
> And I like to think that I have allowed many patients their right to die with *dignity* on their own terms. That is something I would not dare take away.


We're lucky enough to actually _have_ some of the best here on this forum. 


DesertEMT66 said:


> Well I work in California (where you said you used to work).... I also quoted CA state DNR/POLST policy which answers most if not all your questions.


I also used to work in California. DesertEMT did post California's DNR/POLST policy. It's pretty clear what California does and does not permit. 



Chase said:


> And I like to think that I have allowed many patients their right to die with dignity on their own terms. That is something I would not dare take away.





freepratique said:


> I would like to think that too


I _know_ that I took many people home to die with dignity, surrounded by loved ones. Many of those people would have been Code 3 runs to the ED because they were so unstable, or I would have _refused_ transport from the acute care hospital were it not for the DNR/POLST. Instead, I made sure they got home so that they could make their way to the ECU with as little drama as possible.


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## Akulahawk (Aug 10, 2013)

I should also mention that _most_ if not _all_ of the forum members chiming in this thread are quite willing and able to go as aggressive as necessary (within our scope of practice) in providing care for our patients. I'm probably as guilty as pretty much everyone here in going all out in attempting to resuscitate patients that really should have been left alone, because we were required to do it.


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## VFlutter (Aug 10, 2013)

Our hospital has a fantastic Palliative care team that approaches families with end of life decisions. They are great at helping families with DNR/Hospice options. It has really helped reduce the number of futile resusiations and ICU admissions. Unfortunately EMS does not have the luxury. 

Another side note: Let families witness and be a part of codes. Numerous studies have shown it is better for everyone involved. Many people do not realize how violent CPR is or the extent of what we do. I have had families stop a code after I started CPR because they saw, and heard, how intense my compressions are.


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## Akulahawk (Aug 10, 2013)

Chase said:


> Our hospital has a fantastic Palliative care team that approaches families with end of life decisions. They are great at helping families with DNR/Hospice options. It has really helped reduce the number of futile resusiations and ICU admissions. Unfortunately EMS does not have the luxury.
> 
> Another side note: *Let families witness and be a part of codes*. Numerous studies have shown it is better for everyone involved. Many people do not realize how violent CPR is or the extent of what we do. I have had families stop a code after I started CPR because they saw, and heard, how intense my compressions are.


Not only that, but if you're able to spare someone to provide care for the family and keep the family informed as the code progresses, the family has an even better understanding what happened and will more readily accept the termination of the code and the death of their loved one. It may also keep the family from suing because something wasn't done during the code. They may still sue because they may think something went wrong that caused the code... but not because of the code itself.


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## Rialaigh (Aug 11, 2013)

freepratique said:


> Ok then
> Tell me where I don't understand
> 
> If the patient is alive what does a DNR have to do with this?
> ...



Your missing the point of what I am saying. If the patient has a DNR it almost always alters how THEY want to be treated when they are alive. Most elderly patients with DNR's that I have encountered do not want to be placed on Cpap, don't want a breathing treatment, don't want nitro paste, etc..etc...etc..


No a DNR does not mean do not treat, however for me it means I am extra careful to completely abide by the patients wishes regarding what treatment they do want, and often times that treatment is pretty close to nothing. I have no problem not putting oxygen on someone satting 70% because they are a DNR *AND* they have said they do not want oxygen, if they go unresponsive afterwards I am not going to put oxygen on them then because we are "supposed to treat", the patient made it clear their wishes and their wishes still stand after they go unresponsive. 

When you encounter someone with a DNR that is decently responsive (Able to make a decision) you should never be asking yourself what your obligated to do or what the best treatment is for the patient, you should be asking yourself (and the patient) what does this patient want, how can I treat this patient the way that they want.


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## Clipper1 (Aug 11, 2013)

I think some of you are stereotyping the DNR and Hospice patient. Not all are elderly terminal patients. Yes, they may be terminal but sometimes you do get the 30 year old woman with breast cancer who is still fighting to spend as much time at home with her kids during her last months with whatever quality of life a hospice program can provide. To have it cut short by something which is reversible like maybe a pneumonia would be a tragedy. 

For hospice patients, listen to the nurse and the family if they are present.  Read the hospice instructions which also will usually include what treatment is acceptable for conditions deemed as reversible. Don't jump to conclusions right away about what this person wants before you get the facts. If anyone has ever been to a cancer survivor walk or some type of event you might be surprised to meet a few who were in hospice at one time.


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## Akulahawk (Aug 11, 2013)

My responses in red, inline to make it easier to respond to your points. 





Clipper1 said:


> I think some of you are stereotyping the DNR and Hospice patient. Not all are elderly terminal patients. I've seen enough to know that. Yes, they may be terminal but sometimes you do get the 30 year old woman with breast cancer who is still fighting to spend as much time at home with her kids during her last months with whatever quality of life a hospice program can provide. *To have it cut short by something which is reversible like maybe a pneumonia would be a tragedy*. Yes, which is why they can still get antibiotics. Cure that infection and their comfort level goes way up. That patient isn't going to get pressors to maintain BP unless the DNR/POLST/Hospice program is terminated or the paperwork clearly allows use of pressors.
> 
> For hospice patients, listen to the nurse and the family if they are present.  Actually, I won't. Not for care directions. I want to see the documents FIRST. Read the hospice instructions which also will usually include what treatment is acceptable for conditions deemed as reversible. It will also tell me who I can legally listen to for care instructions. Don't jump to conclusions right away about what this person wants before you get the facts. I don't. That's because I read the documentation and GET the facts.  If anyone has ever been to a cancer survivor walk or some type of event you might be surprised to meet a few who were in hospice at one time.


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## Einstein (Aug 11, 2013)

re:
Here's one for you: If your patient is clearly altered, has a heart rate of 22 and a BP that's barely palpable and is breathing 4 times a minute, are you going to start CPR? Are you going to hang dopamine or epinephrine, or put the patient on a pacer?This patient does have a valid DNR. This patient clearly isn't dead yet, so by your criteria, the patient is to be treated as full code... 


Hmmm (what was his HR?)(HX?)
Unless I'm rustier than I thought, his patient would get CPR until atropine was on board and effective, reassess everything, High flow into BVM or CPAP until ROSC that was acceptable, reassess everything, and dopamine was  in fact in our protocol.  Pacing of course couldve been option, based on findings, obviously.

How'd I do?


Hey, BTW
does FORUM DEPUTY CHIEF under your name mean youre an administrator of this site?  Im just curious.


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## chaz90 (Aug 11, 2013)

freepratique said:


> re:
> Here's one for you: If your patient is clearly altered, has a heart rate of 22 and a BP that's barely palpable and is breathing 4 times a minute, are you going to start CPR? Are you going to hang dopamine or epinephrine, or put the patient on a pacer?This patient does have a valid DNR. This patient clearly isn't dead yet, so by your criteria, the patient is to be treated as full code...
> 
> 
> ...



You're significantly rustier than you thought. This patient (assuming an adult) has a HR and a palpable pulse, so no CPR. Also, CPAP for an altered hypotensive patient breathing 4 times/minute? Yeah, not so much. No atropine either since I'd probably jump straight to pacing on a patient this critical IF she were not a DNR. If they were a DNR, I'd look at the state and situation specific documents (as has been mentioned ad nauseam) to determine if pacing and BVM ventilations count as life support (hint: they probably do) for this patient. 

Why is this so difficult for you?


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## VFlutter (Aug 11, 2013)

freepratique said:


> How'd I do?



I think Chaz90 answered that. Personally I think that patient should be made comfortable and allowed to die. But what do I know, I am just a lowly EMT. 



freepratique said:


> Hey, BTW
> does FORUM DEPUTY CHIEF under your name mean youre an administrator of this site?  Im just curious.


No, the title underneath the username is automatically generated based on your post count. Or you can create your own. The Admins have Red usernames


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## Handsome Robb (Aug 11, 2013)

freepratique said:


> re:
> Here's one for you: If your patient is clearly altered, has a heart rate of 22 and a BP that's barely palpable and is breathing 4 times a minute, are you going to start CPR? Are you going to hang dopamine or epinephrine, or put the patient on a pacer?This patient does have a valid DNR. This patient clearly isn't dead yet, so by your criteria, the patient is to be treated as full code...
> 
> 
> ...



Your treatment plan is downright scary.

How did CPAP even come up in that? 

No, it changes with your post count. Administrators' names are in red.


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## Akulahawk (Aug 11, 2013)

Let me see...





freepratique said:


> re:
> Here's one for you: If your patient is clearly altered, has a heart rate of 22 and a BP that's barely palpable and is breathing 4 times a minute, are you going to start CPR? Are you going to hang dopamine or epinephrine, or put the patient on a pacer?This patient does have a valid DNR. This patient clearly isn't dead yet, so by your criteria, the patient is to be treated as full code...
> 
> 
> ...


Forum Deputy Chief is a title based on achieving a certain number of posts. Post enough and you'll get that title too.


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## Einstein (Aug 14, 2013)

btw
re larfge debate with dude about handling hr22 patient, i thought about it and remembered how many i had of these and realized it would be quite extreme situation where id jump on cpr for a moment prior to TCP

you were right.

that was a (likely, under most circumstances) a dumb thing to blurt out

but that doesnt mean its not sound under certain circumstances


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## chaz90 (Aug 14, 2013)

Einstein said:


> btw
> re larfge debate with dude about handling hr22 patient, i thought about it and remembered how many i had of these and realized it would be quite extreme situation where id jump on cpr for a moment prior to TCP
> 
> you were right.
> ...



What are you trying to say here? I'm not trying to be rude, but I'm having a bit of trouble following your train of thought.


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## Einstein (Aug 14, 2013)

*EDITED FOR CONTEXT/CLARITY. (DEmedic)*


To
Chaz90
Re; I don't remember thinking you're being rude.
re: train of thought...Hmmmm   Not sure why it was confusing.  

I realized i said something the about treatment the other day that, in retrospect, could have been a better answer and wanted to admit it.  It was meant for someone else. I'm still learning this site and how my replies make it to the intended person.  So i was just throwing it out there in case they were on line.

have a great one


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## NomadicMedic (Aug 14, 2013)

*Stay on topic please.*

I've removed the off topic posts.


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## eonefireemt3 (Aug 20, 2013)

To me, I would have to agree. If I had a DNR. I would not want you to bag me. If I am suffering, maybe some pain management or sedation. No heroic measures. Beyond that, it falls within what is specified within the DNR and what your state considers to be heroic measures.


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