# DNR/Advanced Directivies.



## Remeber343

I have been thinking about this for a little bit, and our shift had a discussion about it the other day.  Hypothetical, of course, lets say you are toned to a 70 y/o not breathing found by relatives.  I'm sure everyone here is familiar with DNR orders or Advanced Directives.  Lets say that the above patient has signed/legal DNR/AD and wishes to not be resuscitated.  

I have a few different scenarios for this:

1) You arrive, patient has signed DNR orders, but the family there is frantically screaming and asking you to do everything you can for the patient.  It was an unwittnessed arrest, patient was just found.  You tell the family you wish to respect the deceased wishes, and you deny any resuscitation attempts.  The family become agitated and start to get aggressive.

1a)  You arrive, the patient was a witnessed arrested.  Same as above, signed DNRs but the family is frantic and becomes agitated and aggressive towards you and your partner.

2) Witnessed arrest, before the patient went into arrest, the family state he said "Don't let me die, I don't want to die yet".  Pt has signed DNR.  

I'm just seeing what anyone eles opinions/thoughts are on these.  I find it somewhat difficult at times.  Its a legal document, and you have to respect the patients wishes.


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## JPINFV

1: Resuscitate
1a: Move to ambulance, resuscitate
2: Resuscitate 


Note: Your best resource is to look up your company/regional/state policy regarding honoring DNRs. Yes, it's a legal document, but you don't know what was said prior, both immediately and in the days/weeks/months leading to the arrest.


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## Epi-do

I agree with JP.  In all 3 situation you described, it would be best to begin resuscitation, head for the truck, and let the hospital deal with the family. 

I have always been told that if the family requests efforts be made, you go ahead and start CPR, despite the DNR.  Also, if there are ever any doubts about the DNR or it's validity, start CPR.  (This it the policy of my department, mind you.)  Especially, if the scene is deteriorating and your safety is becoming an issue.  Sometimes, the circumstances dictate that you have to make decisions your wouldn't ordinarily make.


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## JPINFV

Another thing. It's easier to stop CPR after having someone discuss the situation with the family members than it is to start CPR after having someone discuss the situation with family members.


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## Smellypaddler

I don't know if it is the same in the USA as Australia but what condition does he have the DNR for?

I mean if he has cancer and doesn't want to be resus'd if he arrests as a complication to his cancer it is different to if he arrests due to a FBAO.

If the DNR order is valid and witnessed it doesn't matter what the family want as it is the patients wishes not to be resuscitated.  Resuscitated does not just mean saved but means being tubed, have your chest thumped on and lines put in your arms.

If I was on this job I would not start resus and would start talking my way out of the aggressive  situation.  Failing that I'd go sit in the truck, lock the doors and call for PD backup.

For those of you who advocate starting resus, what do you do if you somehow get a ROSC on scene or before arrival at the hospital?

If that was me and I woke up due to your resus efforts I would be off to my ambulance chasing lawyer and suing the pants off you.


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## JPINFV

Smellypaddler said:


> For those of you who advocate starting resus, what do you do if you somehow get a ROSC on scene or before arrival at the hospital?
> 
> If that was me and I woke up due to your resus efforts I would be off to my ambulance chasing lawyer and suing the pants off you.




In this situation, an immediate family member has revoked the DNR, therefore if ROSC is obtained the crew should proceed as normal. 

Since an immediate family member has revoked the DNR, you would have no cause for action against the EMS crew.


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## DesertMedic66

As long as there is a valid DNR order then I am not going to start CPR. If the family starts to get aggressive then try to talk them down. If that doesn't work then leave the scene and call PD. 

If however the DNR order gets lost or destroyed then I will start CPR.


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## Remeber343

JPINFV said:


> Since an immediate family member has revoked the DNR.



This brings me to another point, can a family member revoke the DNR? I do not believe A Family member can.  POA might be able to, with compelling evidence. 
 I know my stance on this subject, just trying to get people to think.  We dont come across situations like this that often, its good to maul over them every once and awhile.


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## JPINFV

Remeber343 said:


> This brings me to another point, can a family member revoke the DNR? I do not believe A Family member can.  POA might be able to, with compelling evidence.
> I know my stance on this subject, just trying to get people to think.  We dont come across situations like this that often, its good to maul over them every once and awhile.




What state are you in (and if in California, what county)? The following is, in my experience, a common part of prehospital DNR policies. Maybe "revoked" is a little strong, but it's in effect the same result.




> F. Base contact should be made and the Base Physician consulted and resuscitation should be initiated:
> 1. If there are any questions regarding validity of the DNR order, or
> ...
> 5. If there is disagreement among family members regarding the withdrawal of resuscitative measures, or
> 6. Anytime EMS personnel have concerns or require assistance.


-Orange County Local EMS Agency DNR policy
http://www.ochealthinfo.com/docs/medical/ems/P&P/330.51.pdf

So if I have family members on scene asking me to resuscitate, I've got 3 reasons alone why I should start resuscitation and contact a base hospital.


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## DesertMedic66

My policies say nothing about family members so it's not a choice.


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## JPINFV

firefite said:


> My policies say nothing about family members so it's not a choice.



I know... I was going to reply with a link, but then I read the Riverside protocols and was surprised that they weren't there.


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## Remeber343

"So if I have family members on scene asking me to resuscitate, I've got 3 reasons alone why I should start resuscitation and contact a base hospital"

Youre saying that if the family members want resuscitation and there is a DNR order that is there and valid you are going to attempt to resuscitate?


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## wyoskibum

Depends on which state you are in.  In the wake of the Terry Shivo situation quite a few years back, some states changed their laws to allow the family to supersede DNRs. If you have ant doubt, look up you state statutes.


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## Cup of Joe

In NY, we may ignore a valid DNR:


Any case where there is reasonable evidence to suggest that the DNR order has been revoked or cancelled.
If the patient is conscious and states that they wish resuscitative measures, the DNR Form should be ignored.
If the patient is unable to state his or her desire and a family member is present and requests resuscitative measures for the patient and a confrontational situation is likely to result, if the request is denied.
A physician directs that the order be disregarded.


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## firetender

Remeber343 said:


> I have been thinking about this for a little bit, and our shift had a discussion about it the other day. Hypothetical, of course, lets say you are toned to a 70 y/o not breathing found by relatives. I'm sure everyone here is familiar with DNR orders or Advanced Directives. Lets say that the above patient has signed/legal DNR/AD and wishes to not be resuscitated.
> 
> I have a few different scenarios for this:
> 
> 1) You arrive, patient has signed DNR orders, but the family there is frantically screaming and asking you to do everything you can for the patient. It was an unwittnessed arrest, patient was just found. You tell the family you wish to respect the deceased wishes, and you deny any resuscitation attempts. The family become agitated and start to get aggressive.
> 
> 1a) You arrive, the patient was a witnessed arrested. Same as above, signed DNRs but the family is frantic and becomes agitated and aggressive towards you and your partner.
> 
> 2) Witnessed arrest, before the patient went into arrest, the family state he said "Don't let me die, I don't want to die yet". Pt has signed DNR.
> 
> I'm just seeing what anyone eles opinions/thoughts are on these. I find it somewhat difficult at times. Its a legal document, and you have to respect the patients wishes.


 
I understand this is theoretical but how are you going to know there is a DNR order (signed) unless the family gives it to you? That would mean one family member wants you to honor it and another doesn't. Not a good scene!

Since we're not lawyers and cannot interpret legal documents (no matter who shows you what!), I'd say in all three cases, begin resus, get the pt. into the ambulance and get his doctor on the line for permission to call it or continue.

If your ambulance service has records on individual pts with DNRs (like "expected deaths") then you have to follow the protocol for it, regardless of the wishes of the relatives.

And how do you know who's really in charge? Again, they'd have to prove power of attorney and you can't interpret that document either, and don't have the time to mess around.

The scenarios, as you describe them, are asking you to play Tug of War!


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## JPINFV

Remeber343 said:


> "So if I have family members on scene asking me to resuscitate, I've got 3 reasons alone why I should start resuscitation and contact a base hospital"
> 
> Youre saying that if the family members want resuscitation and there is a DNR order that is there and valid you are going to attempt to resuscitate?


For the vast majority of protocols sets I've seen? Yes.

In EM/EMS position where we are operating off of limited information and without being bound by protocols, I would still argue that the proper course would be to resuscitate. To reiterate what I said earlier, I have no clue what the patient said before arrest. To choose to not resuscitate is final and can't be undone. On the other hand, medical care and resuscitation can always be removed later.


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## Smellypaddler

My post about suing was in regards to the law here.

Unless a family member has a signed medical power of attorney then they can't make a decision regarding the health care of their other family members.

So regardless of what they say, scream or do it is the right of the patient to not have resuscitation started.


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## JPINFV

Since you can't interpret legal documents, then how do you know who has power of attorney?

Similarly, how do psych holds work, since those are legal documents that you can't interpret?


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## JPINFV

Smellypaddler said:


> My post about suing was in regards to the law here.
> 
> Unless a family member has a signed medical power of attorney then they can't make a decision regarding the health care of their other family members.
> 
> So regardless of what they say, scream or do it is the right of the patient to not have resuscitation started.


So then it stands to reason that if a patient becomes incapacitated due to a medical condition (say, intubated, sedated, and being treated in the ICU), the physician makes all medical decisions without input from the immediate family until the court appoints a medical power of attorney?


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## Underoath87

firetender said:


> I understand this is theoretical but *how are you going to know there is a DNR order (signed) unless the family gives it to you?* That would mean one family member wants you to honor it and another doesn't. Not a good scene!



Exactly.  And chances are, the person handing you the DNR is also going to be the power of attorney or the next best thing on scene, so this is pretty much a non-issue.
In the real world, there would be little chance of conflict here unless you found the DNR in the PT's pocket or something.


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## emtCstock

I agree with fire, if they do have a valid DNR I would not resuscitate, if they are getting hostile, move the patient to the unit and call PD. California is pretty stern on DNR's as well as local protocols, you have to take those into effect.


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## emtCstock

Agree with Firefite*


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## JPINFV

emtCstock said:


> I agree with fire, if they do have a valid DNR I would not resuscitate, if they are getting hostile, move the patient to the unit and call PD. California is pretty stern on DNR's as well as local protocols, you have to take those into effect.




So... you'd ignore your LEMSA's (Fresno County is a part of the Central California EMSA group) policy for handling DNRs after talking about taking local protocols into consideration?



> B. If the patient is conscious and states that he/she wishes resuscitative measures, the DNR order shall be ignored. If the patient is unable to state his/her desires, and the patient's legal representative or conservator (if patient legally incompetent) or *a family member is present who wishes resuscitative measures be provided, resuscitation shall be undertaken, since such person's objection may raise questions about the validity or applicability of the DNR order.* It is important to remember, however, that the patient ultimately has the right to determine the course of his or her own medical care. In situations where the DNR order does not seem to apply, then EMS personnel shall not honor the order and shall immediately initiate basic CPR and contact a Base Hospital for direction.


Emphasis added
http://www.co.fresno.ca.us/uploaded...,_Kings_and_Madera_Counties/500_-_699/564.pdf

...and to be clear, if you want to make an argument outside of protocols then by all means do so. However I don't think it's legitimate to say, "I wouldn't do X, but follow your protocols" when your own protocols says to do X.


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## OrlandoRMAMedic

our protocols state that if there is any question about the validity of the DNR.  I thought that there had been mention about family member input, but it says, and I quote
"♦ When presented with a State of Florida Yellow DNR Form 1896 or State of Florida Yellow DNR Device which is a miniature copy of DNR Form 1896
 The form must be properly completed, including physician signature.
♦ If unknown DNR status or question of DNR status, initiate resuscitation
Note: A Living will is not equivalent to a DNR form and resuscitation is required unless the above criteria are met."

I just learned something new.  It may have been the protocols to my volley county that has that in there... now I am going to have to go find those and look it up.  I have never been faced with an issue like this.   Most of my DNR pts are in a nursing facility of some sort or in hospice.

** I found the other counties protocol online and it falls in line with the county that I get paid to work in

"Terminally ill patients present ethical and legal questions when making resuscitation decisions. Frequently, surviving family members will direct that resuscitation should not be attempted. The questions associated with the “Death with Dignity” issue are important, emotional, and beyond the ability of an EMS system to address.
A. The State of Florida’s “Do Not Resuscitate Order” (DNRO) form will be honored as long as the form is either an original or the form is a copy on yellow paper. The form must be complete and signed. If there is doubt of the authenticity of the form or the form is not a State of Florida DNRO form, resuscitation will be performed on the patient unless another section of this protocol applies.
B. If a patient does not have a DNRO, but is terminally ill, decrepit, and in the end-stage of the disease process, contact medical control for orders to cease resuscitation."


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## Smellypaddler

JPINFV said:


> So then it stands to reason that if a patient becomes incapacitated due to a medical condition (say, intubated, sedated, and being treated in the ICU), the physician makes all medical decisions without input from the immediate family until the court appoints a medical power of attorney?



Shocking but true.

The treating physician makes decisions about patient care.  Those tricky decisions such as turning off life support etc go before an ethics committee at the hospital.

A family member or next of kins wishes are considered but have no legal standing.


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## KellyBracket

This sounds a lot like the scenario that some Texas medics faced in '08.

This can be a thicket of issues; legal, ethical, medical, and perhaps most importantly, practical. There is an opportunity to get things real wrong if you try to analyze things in a hectic environment, and this hardly applies only to EMS. 

There is a tremendous opportunity to screw things up on these things, and EMS should not feel like they have to make the final call on their own. 

Sounds like I should tackle this issue, with an emphasis on Connecticut policies, in my next blog post!


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## JPINFV

KellyBracket said:


> There is a tremendous opportunity to screw things up on these things, and EMS should not feel like they have to make the final call on their own.


The final call? I agree, EMS shouldn't have to make it alone. However, EMS providers have to make the first call, and there's only one option available for the first call that allows for consultation before making the final call.


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## triemal04

Remeber343 said:


> 1a)  You arrive, the patient was a witnessed arrested.  Same as above, signed DNRs but the family is frantic and becomes agitated and aggressive towards you and your partner.
> 
> 2) Witnessed arrest, before the patient went into arrest, the family state he said "Don't let me die, I don't want to die yet".  Pt has signed DNR.
> 
> I'm just seeing what anyone eles opinions/thoughts are on these.  I find it somewhat difficult at times.  Its a legal document, and you have to respect the patients wishes.


The first two are the same.  Make an attempt to explain to the family what is going on, why it is happening, and that you are following the patien'ts wishes.  Remember that this is a terrible moment for them, and they really are your patients now.  If needed, back out, call for a police responce, making sure that they know that it's not for an emergent problem.  And take the DNR with you.  

The third...punt that one.  Start basic CPR, get as much info as you can about the patient's medical history and why they have the DNR in the first place, and then make a discrete phone call to whoever your medical control is.  

In each case, be very sure that it really is a valid DNR. (in this area there is a push to have them on the refridgerator door)  And woe to you if you live somewhere where a family member can retract a patients advance directives.


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## Nervegas

I can see where a living will would get into a grey area, but in TX if I am presented with a valid DNR, or they have an OOH-DNR identification tag/bracelet etc, I can honor it. Only the patient can revoke that DNR, regardless of what the family says. If a family member tells me that with their dying gasp they revoked the order I can still honor the original DNR - _"(d)  Except as otherwise provided by this subchapter, a person is not civilly or criminally liable for failure to act on a revocation made under this section unless the person has actual knowledge of the revocation."_

When in doubt, contact OMC and discuss it with them.


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## DrankTheKoolaid

*re*

In all three cases I would not begin resuscitation.  If family is agitated I would move patient to the rig and leave for safer grounds while law enforcement was dispatched.  

My first field save was a cancer patient that I knew for sure would have been a DNR, but the transporting VFD that met us with the patient did not bother to look for or find out if patient was DNR.  Quick hand off and away we went.  During the 30 minute transport to the ED patient coded on me and ROSC was achieved...  Upon arrival at the ED patient is still altered and within 5 minutes patient is talking and the first question the MD asked was do you have a DNR signed. "Yes I do"  Talk for a few minutes and when he found out he was resuscitated he closed his eyes and would not say another word to anyone.  He was then admitted and died 5 days later after refusing to eat drink or take any meds.  Not only was it hard on the patient, that was hard on all staff involved. Never and I mean NEVER will I do that to another human being who has made the conscious decision to die with dignity.  

Here is a link of our DNR Policy, pay particular attention to this line.

AUTHORITY: Health and Safety Code Division 2.5, Section 1797.220 and 1798. Bartling V. Superior
Court, 163 Cal. App. 3d 186, 195 (1984), which ruled “The right of the competent adult patient to refuse medical
treatment is constitutionally guaranteed right which must not be abridged.”

http://www.norcalems.org/pnp-manual...ient_Care_Policies/302_Do_Not_Resuscitate.pdf


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## JPINFV

Corkey, would the family questioning a DNR make the validity of the DNR questionable in your mind?

From your link:


> 3. In unusual cases where the validity of the request is questioned, prehospital personnel should disregard the DNR request, institute BLS resuscitative measures. ALS providers should contact the base hospital immediately for direction.


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## DrankTheKoolaid

*re*

If the DNR is questionable to ME is how I read that.  I don't really care if a family member questions it if it meets all the criteria and appears valid and has not been tampered with. (qualifying this last line) At the final moment of a patients life I have seen family members with every emotion imaginable in reaction to their loved ones death.  Even with terminal end stage diseases have I witnessed various family members who have not been in the right place on the grief wheel have a very hard time with death, though this death was in no way unexpected and in some cases the patient lived weeks if not months longer then anticipated.  I don't want to come off as cold, as I am not.  But I will also be the first to step up and use the words dead and has died.  This is not a time for sugar coating nor is it a time for using any other phrase that does not clearly mean this person is dead and is not coming back.  And I am also the person who immediately switches roles and begins to contact clergy (after asking if they would like me to, as an atheist it took me a while to do this naturally) and other family members and assisting them in making final arrangements if they don't know how to go about it. 

But in the end, if the family put up that much of a fight I would have BLS care initiated while attempting to contact base hospital if in an area where they either have a home phone or I have cell service.  Which in my neck of the woods is certainly not a given.  But if I have no way of making contact and DNR appears valid, that's the end of it.


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## mycrofft

Find out about the local laws about "unaccompanied deaths". Even if you respect the paper, you might be legally required to notify law enforcement or the coroner's office about a death which did not occur while under medical care.

(BTW, a *coroner* is the legal representative for the dead, and the coroner's office often includes the _*medical examiner*_, who does the autopsy. In the old days, often they were one in the same, but not very common nowadays. The coroner most often is busy doing things like finding next of kin to notify and take possession of the deceased's estate, making assure pets are sent to an animal shelter, securing the real property.


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## DrankTheKoolaid

*re*



mycrofft said:


> Find out about the local laws about "unaccompanied deaths". Even if you respect the paper, you might be legally required to notify law enforcement or the coroner's office about a death which did not occur while under medical care.
> 
> (BTW, a *coroner* is the legal representative for the dead, and the coroner's office often includes the _*medical examiner*_, who does the autopsy. In the old days, often they were one in the same, but not very common nowadays. The coroner most often is busy doing things like finding next of kin to notify and take possession of the deceased's estate, making assure pets are sent to an animal shelter, securing the real property.



Excellent reminder there.  Thankfully not an issue for us here as S.O. dispatch is also our dispatch and know what we are doing.  And usually a Deputy is dispatched along with us to any report of a code or overdose


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## triemal04

Corky said:


> In all three cases I would not begin resuscitation.  If family is agitated I would move patient to the rig and leave for safer grounds while law enforcement was dispatched.


If you didn't plan on doing anything, why take the body with you?  Liability?  Personal safety?  Just curious.


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## DrankTheKoolaid

*re*

Grab the body, move to truck, family assumes something is being done and they calm down.  By that time LEO have typically arrived and then it's a null point anyway.  But in reality I have only had to do this at SIDS deaths.  Never in an adult or at a DNR.

I guess I could always just back myself and partner back into the rig, but in almost 20 years of doing this it has never come to that.  Family has always realized after either myself or partners have talked with them that the patient is dead..   To be honest I have seen more drama while working in the ED at deaths, then I have in the field.  This I really think relates back to most typical ED's dont allow a ton of family members into the room during the resus or lack there of, where in the field we are front and center stage in the living room bedroom or where ever.  Studies have shown that it helps the grieving process to actually be present during the resuscitation or at the time of expiring.  So I attribute the lack of drama in the field to this.


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## Remeber343

I'm my area if it is not a pending home death, Leo is dispatched for investigation. We are not able to move the body once we call it. Then after they do their investigation the corner picks them up.


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## R99

While the wishes of the family should be taken into consideration the family are not the patient so sorry at the end of the day it dont matter jack what they want if the patient has a clearly described directive then it is unethical for us not follow it

attempted resuscitation from cardiac arrest and out of hospital recognition of life extinct is just about the Intrusive and undignified thing you can have happen to you, why subject the patient and family to that if not completely necessary?


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## johnrsemt

Just remember that if you move the patient to the truck for safety/ clarification with the hospital, etc:  and get orders to call the code or stop CPR and call the code:  that in most locations your truck is now a potential crime scene until the coroner/Medical Examiner releases the body.

   In my old service we had that happen twice, once they had the body for almost 7 hours in the truck.  (That really screws up dispatch; because no matter how many pages and radio traffic you are out of service).

  One crew was dispatched for mild difficulty breathing;  when they got to the patient (BLS) they had basic Airway equipment:  BVM, O2 tank, NRB, and NC.  The patient was in full arrest; and rigored and with lividity present.  They put the pt on the cot; called for ALS headed for the truck, starting CPR.  (They weren't comfortable calling the pt at the scene, even though it is in the protocols there for BLS).  ALS was 2 blocks away, got there as the pt got to the truck;  called ED to confirm calling the pt (since CPR was started already).  Then the ALS crew gave the pt back to the BLS crew; and called for the PD to come start their paperwork.  The crew tried to take the body back to the ECF (they were still parked outside)  DON had a cow over that, understandable.    
   The police was upset that they moved the body after declaration of death (going back into the ECF).    
   It took almost 7 hours to get it straightened out;  and the crew was upset about going over then end of their shift, even with the OT.


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## Spedz

Epi-do said:


> I agree with JP.  In all 3 situation you described, it would be best to begin resuscitation, head for the truck, and let the hospital deal with the family.
> 
> I have always been told that if the family requests efforts be made, you go ahead and start CPR, despite the DNR.  Also, if there are ever any doubts about the DNR or it's validity, start CPR.  (This it the policy of my department, mind you.)  Especially, if the scene is deteriorating and your safety is becoming an issue.  Sometimes, the circumstances dictate that you have to make decisions your wouldn't ordinarily make.





Just a FYI (We had just covered this in class) DNR is no good for EMS (not in Indiana anyway) unless its a actual Out of Hospital DNR ( and unfort. not to many people even know of this so there are VERY VERY few out of hospital DNR) (according to my teacher there isnt even a lot of Doctors that know this form is even there):blink:   (not sure why they have done this I think a DNR should be a DNR no matter what...anyway just my 2 cents).......WOW I really am learning something in class....................


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## Spedz

Heres a pic of one was gonna put it on my other post however I didn't realize I only had 15 minutes to edit my post (ok whatever)......


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## JPINFV

Does Indiana have statewide protocols or a statewide DNR policy posted online? The reason I ask is because I can't find anything on Indiana EMS's website, but did find the following document dated from 2010:

"B. Do Not Resuscitate (DNR) orders:
1. If health care personnel or family members are present at the scene of a patient in cardiopulmonary arrest and request that resuscitative measures be withheld, request to see a DNR order that has been signed by the attending physician. If presented, resuscitative efforts should not be initiated or may be terminated.

2. In the event the family or health care personnel cannot produce this document immediately, begin resuscitative efforts in accordance with the *appropriate protocol* and transport. 

3. If there is any question regarding the validity of the written order, resuscitative measures should be initiated. Contact the receiving facility for further orders.

These guidelines do not apply to a *Living Will*."

pg. 12
http://www.decaturfire.org/2010EMSPROTCL.pdf

Nothing specific is said about requiring a specific DNR format. Point 3 would be used in the OP scenarios to begin resuscitation pending base hospital contact.


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## Spedz

JPINFV said:


> Does Indiana have statewide protocols or a statewide DNR policy posted online? The reason I ask is because I can't find anything on Indiana EMS's website, but did find the following document dated from 2010:
> 
> "B. Do Not Resuscitate (DNR) orders:
> 1. If health care personnel or family members are present at the scene of a patient in cardiopulmonary arrest and request that resuscitative measures be withheld, request to see a DNR order that has been signed by the attending physician. If presented, resuscitative efforts should not be initiated or may be terminated.
> 
> 2. In the event the family or health care personnel cannot produce this document immediately, begin resuscitative efforts in accordance with the *appropriate protocol* and transport.
> 
> 3. If there is any question regarding the validity of the written order, resuscitative measures should be initiated. Contact the receiving facility for further orders.
> 
> These guidelines do not apply to a *Living Will*."
> 
> pg. 12
> http://www.decaturfire.org/2010EMSPROTCL.pdf
> 
> Nothing specific is said about requiring a specific DNR format. Point 3 would be used in the OP scenarios to begin resuscitation pending base hospital contact.





Is this what your asking for? If not I will try to find more info and again just what I was taught in class lol





http://www.in.gov/legislative/ic/2010/title16/ar36/ch5.html


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## JPINFV

I came across that too, and it looks like it falls short of mandating it in favor of authorizing it.  Here's my two issues with requirng a specific form. 

1. If you're doing a discharge or transfer from an acute care hospital, since they do not have to follow an OOH DNR form, can you accept their in-house DNR form/order?

2. Same question as 1, but from a health care facility like a nursing facility?

To me, it makes no sense to limit the acceptable options in those situations.


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## Spedz

According to class NO YOU MAY NOT accept any DNR unless its the out of hospital one no matter what.


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## jjesusfreak01

I'll use any excuse to throw a NC DNR out the window, as I have absolutely no idea whether it represents the will of the patient or the family. It only needs the patient's name and a Dr's signature on it. If they would change the stupid form to require signatures from the patient or POA, I would have no problem honoring it against the families wishes (assuming it was legal for me to do so). 

I just can't in good conscience honor a form that a competent patient may have never seen or been asked about before arresting.


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## JPINFV

What physician is his or her right mind would sign a DNR without discussing it with a competent patient, or an incompetent patient's POA? 

Note: POA doesn't necessarily require a legal document, as most, if not all, parts of the US are going to have some way of allowing family members to make treatment choices in the event of an unexpected catastrophic medical disorder or injury that removes the patient's ability to make a choice, such as someone who suddenly finds their way to being on a vent in the ICU.


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## Melclin

Remeber343 said:


> I have a few different scenarios for this:
> 
> 1) You arrive, patient has signed DNR orders, but the family there is frantically screaming and asking you to do everything you can for the patient.  It was an unwittnessed arrest, patient was just found.  You tell the family you wish to respect the deceased wishes, and you deny any resuscitation attempts.  The family become agitated and start to get aggressive.
> 
> 1a)  You arrive, the patient was a witnessed arrested.  Same as above, signed DNRs but the family is frantic and becomes agitated and aggressive towards you and your partner.
> 
> 2) Witnessed arrest, before the patient went into arrest, the family state he said "Don't let me die, I don't want to die yet".  Pt has signed DNR.
> 
> I'm just seeing what anyone eles opinions/thoughts are on these.  I find it somewhat difficult at times.  Its a legal document, and you have to respect the patients wishes.



This seems like an issue of personal safety rather than medical ethics.

1. DNR, agitated potentially violent family, unwitnessed arrest: Explain better if you can, retreat if you can. If not start resus. My life and well being is worth more than their end of life wishes. They're dead anyway and I don't feel like joining them.

1a. DNR, agitated potentially violent family, witnessed arrest: What does it being witnessed have to do with it? See step one.

2. Depends on whether or not he's past the point of resus. If he's past resus, don't (if they get violent, see step one). If he's viable, I'd start. I'm acting, in good faith, on what I believe the pt's wishes are as conveyed to me via the family. That is enough for me.


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## jjesusfreak01

JPINFV said:


> What physician is his or her right mind would sign a DNR without discussing it with a competent patient, or an incompetent patient's POA?
> 
> Note: POA doesn't necessarily require a legal document, as most, if not all, parts of the US are going to have some way of allowing family members to make treatment choices in the event of an unexpected catastrophic medical disorder or injury that removes the patient's ability to make a choice, such as someone who suddenly finds their way to being on a vent in the ICU.



Well, we have the nursing home docs, and then we have the hospitalists who seem to sign a DOR for just about every geriatric patient discharged from the hospital following a debilitating injury. It may be that most of these DORs have been discussed with the patients and families, but I just don't know, because there's no evidence. 

We have a secondary form in NC called a MOST form that requires the patient (or legal representative) signature in addition to a high level provider (MD/DO/PA/NP), and it must be reaffirmed (and resigned) by the patient and provider at any time there is a major change in facility or major change in health status. This is what the DOR should be.


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