# Honoring a DNR



## Eric_Milam (Apr 29, 2007)

I need soem clarification regarding DNR's. I know that EMT-B cannot pronounce death. Are we required to honor the DNR. In my situation we dont have medics. We are a BLS transport company with to Basics on board. There is a buzz goig round the county that basics cannot pronoounce so they cannot honor a DNR that would be failure to act. The CA protocols dont go into details, but alway refer to having a medic on board, or a Dr. and old protocols even state having two intermediates. Anyone who can shed some light would be helpful


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## MMiz (Apr 29, 2007)

Welcome to EMTLife!

What do your county protocols says?  Ours are *very* clear in this situation, and EMT-Basics can pronounce a patient dead.  What about during a decapitation or rigor mortis, you're telling me that you have to work the patient all the way to the hospital?

I'm going to assume your county protocols have very detailed information on the situation.  You may want to refer to those first.


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## medicdan (Apr 29, 2007)

From what I understand, only a Medical Examiner can sign a death certificate. We can assume (and not treat) death in a few cases that include:
-Rigor Mortis
-Decapitation or severed trunk
-Seeing significant brain matter
-Highly significant blood loss
-Decomposing tissue

I think there are several more but I am blanking on them now... But in all other cases, we NEED to resucitate and transport to an ER.  In cases above, we can call the Medical Examiner (but I dont think we can leave the scene until the ME arrives= higher qualifications..?)

In terms of DNR-- MA has a set of laws on the books called Comfort Care-- a pt can, with their MD sign a document that is a DNR. The PT is required to wear a bracelet and have the original document in easy access. If we dont find the bracelet AND the document, we need to resucitate.


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## Ridryder911 (Apr 29, 2007)

It is all dependent on local and state policies and laws. EMT's may not pronounce but they can declare death. Do Not Resuscitation (DNR) & Living Wills are both legal documents and authorization. Legally, if one does perform resuscitation upon one that does have such orders they technically can be going against a legal wishes. 

DNR has to valid according to local laws and should be up dated and honored if valid. This is the reason they were established to begin with. Remember DNTR and Living Wills are NOT the same and should be honored differently. Living Wills are legal document as well, that actually describe the choice of care (or lack of) and extent of care that is addressed. Such as no IV's or intubation and being placed on ventilator, etc.. 


Remember, DNR ONLY means AFTER they have arrested no care is performed to resuscitate, not to prevent an arrest or restrict care. 

R/r 911


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## KEVD18 (Apr 30, 2007)

emt-student said:


> The PT is required to wear a bracelet and have the original document in easy access. If we dont find the bracelet AND the document, we need to resucitate.




you only need one or the other, bracelet or form. either must be original, or a photocopy if you have seen the original. ex, a dislysis pt i take carries with he a xerox of her dnr. i can legally accept that in the field because, hanging on the wall in her kitchen is the original

you cant pronounce death in this state. medics cant pronounce either. all you can do( or not do depending on view point) is not work the code. in those circ(rigor, pml, decap etc). the me still needs to pronounce.

with one of those situations, or a valid dnr, its not abandonment or failure to tx. its following protocols


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## TKO (Apr 30, 2007)

yeah, what Rid said.

What does pronouncing death have to do with a DNR?  It's essentially just a no CPR-Defibrillation order (usually).  Some will say allow AR but not compressions, etc.  You just need to obey their wishes if the situation arises.  

If you could pronounce death, then there would be no need to attempt to resuscitate, would there?  "Ok, I'm calling it.  Death at 3:53 AM.  BEGIN CPR!!!"  LMAO!

Remember that a DNR must be signed and dated.  If they are not, they are invalid.  And a patient/facility must show it to you when you take care of them otherwise it doesn't exist.  I have had nurses tell me not to worry, there is a DNR.  I tell them there sure isn't until I see it.  We all have rules we have to follow and their laziness is not an excuse to be pissy at me because I'm trying to do my job.  Besides, clerical and drug errors are not uncommon and if you do not resuscitate because a nurse told you there was a DNR and it turns out there wasn't or there were stipulations you didn't see -- that nurse won't even pretend to know you, and you are completely responsible for killing your pt.

Learn what you need to know about DNRs!  Start asking the higher-ups for more info and see to it that everyone in your service knows about it.  This sounds like it could turn into an ugly situation if not looked after.  I have heard some stupid things in my short time; I knew a crew in a transfer company that thought that the DNR meant doing absolutely nothing (in this case, their pt was having difficulty maintaining her airway and they withheld suction because they thought that would interfere with the DNR).  I sorted those boys out, let me tell you.


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## Epi-do (Apr 30, 2007)

As already stated, it really depends upon where you are at, what the local laws are, etc. 

Here, a basic is allowed to determine CPR should not be started under certain circumstances (decapitation, transection, rigor mortis, livor mortis, etc) or if a valid DNR is presented to the crew.  Per our medical director, we cannot honor a "pick-n-choose" DNR on the street.  It must be all or nothing.  Therefore, if the DNR says "chemical resuscitation only" it is the same as them not having a DNR for us.  The only way we can get around this is to call the hospital and request orders to terminate.   

Our medical director has also told us that if the family presents a living will, we have to ask if there is also a DNR order.  Without the DNR, we cannot honor the living will, even if it states "no cpr".  Again, we can call the hospital and talk to a doc to request orders to terminate resuscitative measures, but it is at the docs discretion.


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## BossyCow (Apr 30, 2007)

KEVD18 said:


> you only need one or the other, bracelet or form. either must be original, or a photocopy if you have seen the original.




This depends on the locality.  We need to see the actual, signed, witnessed document.  I've been on calls where either the document has been signed, we've seen it in the past, and husband has ditched it and is saying.. "Do everything!" and the one where patient re-did the document and family/caregiver is saying the older document is the most current.  

In Washington state it's called a P.O.L.S.T Physician's Orders On Life Sustaining Treatment and covers more than just CPR.  It's pretty detailed.  You can give 'comfort measures' pain killers, water, O2 for comfort, nitro for chest pain, or you must do everything.  

Check with your local MPD and see what your local protocols say about this.


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## FF/EMT Sam (May 1, 2007)

Eric_Milam said:


> I need soem clarification regarding DNR's. I know that EMT-B cannot pronounce death. Are we required to honor the DNR. In my situation we dont have medics. We are a BLS transport company with to Basics on board. There is a buzz goig round the county that basics cannot pronoounce so they cannot honor a DNR that would be failure to act. The CA protocols dont go into details, but alway refer to having a medic on board, or a Dr. and old protocols even state having two intermediates. Anyone who can shed some light would be helpful



This is such a broad issue that you really need to ask someone familiar with your local protocols.  All that we can give you are guesstimates and *our* local protocols, which may differ wildly from yours.

That said, when in doubt, do everything that you can for a patient.  It is much better do have to defend yourself for doing CPR and defibulation than to have to defend yourself for watching and doing nothing while a patient died.


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## KEVD18 (May 1, 2007)

thanks for the insight into your protocols. i was only referencing ma rules, but it is interesting to see what its like everywhere else


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## TKO (May 1, 2007)

yes.  Always consult local guidelines and protocols.  That's good advice no matter how many times you hear it.

But as I was trying to get across, don't wait until your pt is pronounced dead to act, because I guarantee you that it is too late.

_"Aaaand the rhythm is asystole.  Finally!  ok, *CLEEEEEAR!!*"_


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## medicdan (May 2, 2007)

*Local Protocols*

Sorry-- If you were asking about MA protocols-- this is the best place to check

http://www.mass.gov/?pageID=eohhs2s...+(DNR)+Order+Verification+Program&sid=Eeohhs2

Enjoy!


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## KEVD18 (May 2, 2007)

emt-student said:


> Sorry-- If you were asking about MA protocols-- this is the best place to check
> 
> http://www.mass.gov/?pageID=eohhs2s...+(DNR)+Order+Verification+Program&sid=Eeohhs2
> 
> Enjoy!



i dont know if reading thast is something someone would enjoy....

just out of curiosity, where are you attending school. i work and teach in the boston area. anything you might be confused on regarding local protocols, feel free to pm me and i'll do my best to shoot your in the right direction.


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## adcantu (May 2, 2007)

what about dnr tattoos? I know of two cases where people had tattood on their chests DNR... 

So you find this old lady (both these cases I believe the women were in thier 80s), take off her blouse, and find these tattoos! what do you do!? well if I were in that situation, I would check her purse or wallet, or her person for any indication of an actual dnr... without that, I would go through treatment lol. A tattoo while clearly stating the pt's wishes, in court I dont think it would hold up. Kind of a tricky ethical / legal sitation  to be in eh?


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## Ridryder911 (May 2, 2007)

Tatto's are not legal binding statements...thank goodness!  I know of several that have the "DNR" tatts. They are considered only a expression of art and expression. 

R/r 911


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## firecoins (May 2, 2007)

Ridryder911 said:


> Tatto's are not legal binding statements...thank goodness!  I know of several that have the "DNR" tatts. They are considered only a expression of art and expression.
> 
> R/r 911



yeah, your forced to have a tattoo your whole life.  Hopfully not in all death as well.


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## Raf (May 3, 2007)

KEVD18 said:


> you only need one or the other, bracelet or form. either must be original, or a photocopy if you have seen the original. ex, a dislysis pt i take carries with he a xerox of her dnr. i can legally accept that in the field because, hanging on the wall in her kitchen is the original
> 
> you cant pronounce death in this state. medics cant pronounce either. all you can do( or not do depending on view point) is not work the code. in those circ(rigor, pml, decap etc). the me still needs to pronounce.
> 
> with one of those situations, or a valid dnr, its not abandonment or failure to tx. its following protocols



From what I've heard in Mass, this is not true. The friends, family, etc of the patient must be able to present the document to you and patient must be wearing matching bracelet. It's both, or you're getting rescuscitated by me.

Again check with local protocols! Anything we say here is meaningless when compared to the law.


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## KEVD18 (May 3, 2007)

http://www.mass.gov/Eeohhs2/docs/dph/emergency_services/comfort_care_form.pdf

above is a link to the mass oems cc/dnr form. unfortunatley, i cant get a graphic of the back where it outline the protocol of accepting it. take my word for it, it states that while wearing of the bracelet is prefferable, it is optional. on the actual braclet insert at the bottom of the form above, you may note that it does say "if used". if not used they are to be destoryed.

the form, or the bracelet, individually serve as the order. you need only one, in the original form. you may also use a photocopy for transport, such a dr appt if you have personally seen the original that day.

without going into detail, i ahve been involved in legal proceeding regarding mass oems comfort care protocols and the honoring of a dnr.


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## KEVD18 (May 3, 2007)

oh yeah, you also have too make every effort to identify the pt(hence why me like the bracelet). if a family member says " i called. its my dad, over there on the floor" thats a reasonable identification

and if you ever decided to work a code with a valid dnr order in front of you, god help you brother cause your screwed.


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## BossyCow (May 4, 2007)

KEVD18 said:


> oh yeah, you also have too make every effort to identify the pt(hence why me like the bracelet). if a family member says " i called. its my dad, over there on the floor" thats a reasonable identification
> 
> and if you ever decided to work a code with a valid dnr order in front of you, god help you brother cause your screwed.



I think I'd rather be explaining why I did than why I didn't.


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## Mercy4Angels (May 5, 2007)

paramedics can pronounce death but the ME has to declare it and sign the paperwork. emt basics can still only do nothing. my suggestion is if your looking for more responsibility be a medic.


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## MikeEMT609 (May 11, 2007)

I've been an EMT for 22 years in Los Angeles. The EMS agency issued a policy regarding DNR's and the company did the same.

Basically, a DNR patient belongs at the facility of choice whether that's a hospital, extended care facility or residence (the last two refer to discharges from the hospital).

Whenever I transport a patient I always ask the patient's code status and check the transfer paperwork to confirm what the nurse tells me, and if the patient is going home then I'll ask to see the DNR order before we leave the facility.

When you transport these patients you provide comfort measures which can include positioning of the patient, oxygen and suctioning to maintain their airway.

If the patient dies in your care then confirm the death and note the time on your paperwork.

We had this happen to both my partner and myself recently. In the case of my patient, we were transporting to an extended care facility and she died about 10 minutes before arriving at the facility.
On arrival my partner went inside the facility to let them know what happened, then we took the patient inside and left her in a private room.

In the second case we transported from an extended care facility to the emergency room, and shortly after arriving (in the presence of the nursing staff and the ER MD the patient died.

As EMT's all we can do is confirm a DNR order is in place, and if the patient stops breathing then note the time in your paperwork, and if there is no DNR then work up the patient and divert to the closest ER.


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## Mercy4Angels (May 12, 2007)

Eric_Milam said:


> I need soem clarification regarding DNR's. I know that EMT-B cannot pronounce death. Are we required to honor the DNR. In my situation we dont have medics. We are a BLS transport company with to Basics on board. There is a buzz goig round the county that basics cannot pronoounce so they cannot honor a DNR that would be failure to act. The CA protocols dont go into details, but alway refer to having a medic on board, or a Dr. and old protocols even state having two intermediates. Anyone who can shed some light would be helpful



as long as you have the DNR WITH YOU ! signed by a physician then yes you have to honner it.


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## Guitarplaya84 (May 12, 2007)

You actually have to have the DNR in hand. if someone says that they have a dnr.... by law you have to resucitate until they get that dnr in hand. no ifs ands or butts about it...


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## Onceamedic (May 26, 2007)

*Here in Wisconsin*

they gotta have the bracelet and its got to be on....  its a problem cause in the nursing homes the caregivers like to leave them off ( guess it saves them .3 minutes during baths or something)  then when you go to pick them up they bring you the bracelet on a clipboard..
sucks big time because if the patient is non responsive, how do we know if they took it off because they wanted to rescind the DNR or WHAT ?

The rule for us is if they are not wearing it then it is not a valid DNR...

that being said,  we were taking in a 83 year old from hospice to hospital for pain relief...  the EMT-P had pushed 40mg of morphine and the guy was still hurting...
if he had coded, we were supposed to start pounding on him ???    thank god he didnt...


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## Thanach (May 26, 2007)

Mercy4Angels said:


> paramedics can pronounce death but the ME has to declare it and sign the paperwork. emt basics can still only do nothing. my suggestion is if your looking for more responsibility be a medic.



Again, that's a local protocol thing

Take for instance, this memo sent out in mass 3 years ago

http://http://www.mass.gov/Eeohhs2/docs/dph/emergency_services/ambulance_pronouncement_death.pdf

where no matter what level, unless it's obvious they're dead, they ain't dead


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## Jon (May 26, 2007)

It varies by protocols... both state and regional.

In PA, we have a state DOH approved Out-Of-Hospital DNR. It involves a hospital-type bracelet as well as paperwork. Without both, it isn't legally binding for us.

If we have a DNR that is not the official Out Of Hospital DNR, we work them and consult with Medical Command. Medical Command will PROBABLY OK termination of efforts... but it is why he/she pays the big bucks for medical malpratice insurance.


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## Raf (Jun 1, 2007)

As of January 2007 in MA: Only Comfort Care DNR's are honored. Either original or copy, or bracelet is acceptable. Only one needs to be seen.


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## VentMedic (Jun 2, 2007)

Raf said:


> As of January 2007 in MA: Only Comfort Care DNR's are honored. Either original or copy, or bracelet is acceptable. Only one needs to be seen.



Comfort care DNR and DNR can be 2 very different documents. Nursing homes may have both.  DNR pts will be treated in the hospital same as any other patient (and in some cases CPAP or other forms of Non invasive ventilation)  up until the time of more heroic measures.  Comfort care DNRs are those that are being allowed to die without intervention except pain meds, O2 and whatever the predetermined comfort will be above that.  It would be important to know the type of documentation used/recognized by the State and local facilities. Hospice patients also have specific documents usually called a Comfort Care Only document that are different from other forms of DNRs.  Living wills are also different documents as Ridryder911 mentioned earlier.  Lots of room for confusion if you don't have clear guidelines with the different documents honored in your area. 

Many physcians and for that matter patients are reluctant to have a DNR order made in fear it will be interpreted as a "Do Not Treat".   Thus, that is one reason there are so many elderly people in the nursing homes without DNRs.  I hear too ofter from ambulance crews and hospital staff, "they're just a DNR"  or "why bother" type of care.  For these reasons, my 91 y/o mother remained a full code until we put her into hospice.


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## MikeEMT609 (Jun 2, 2007)

VentMedic said:


> Comfort care DNR and DNR can be 2 very different documents. Nursing homes may have both.  DNR pts will be treated in the hospital same as any other patient (and in some cases CPAP or other forms of Non invasive ventilation)  up until the time of more heroic measures.  Comfort care DNRs are those that are being allowed to die without intervention except pain meds, O2 and whatever the predetermined comfort will be above that.  It would be important to know the type of documentation used/recognized by the State and local facilities. Hospice patients also have specific documents usually called a Comfort Care Only document that are different from other forms of DNRs.  Living wills are also different documents as Ridryder911 mentioned earlier.  Lots of room for confusion if you don't have clear guidelines with the different documents honored in your area.
> 
> Many physcians and for that matter patients are reluctant to have a DNR order made in fear it will be interpreted as a "Do Not Treat".   Thus, that is one reason there are so many elderly people in the nursing homes without DNRs.  I hear too ofter from ambulance crews and hospital staff, "they're just a DNR"  or "why bother" type of care.  For these reasons, my 91 y/o mother remained a full code until we put her into hospice.



In regard to what we need to honor a DNR where I work...we can honor the written prehospital care DNR form, signed and dated (home setting) and in the case of someone that's an inpatient of a hospital or convalscent facility we can honor a written DNR order in the patient's chart.
In most cases the order will be in the transfer papers. On every transport I ask the sending nurse the patient's code status and look at the chart (and transfer papers to confirm the status) BEFORE I take the patient.

If the patient is DNR then I continue to treat the patient w/ oxygen and suction if needed. If the patient passes away during transport then we continue to the requested destination.

As I said in an earlier post this happened to me on a transport once (hospital to convalescent)...patient passed during transport so we continued to the convalescent, and when we arrived I had my partner run inside to let staff know what happened so they could find a place for the patient.

Took the patient inside the facility and into a room then gave report to the staff (nursing staff/administrator).


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## emtd29 (Jun 2, 2007)

Mercy4Angels said:


> paramedics can pronounce death but the ME has to declare it and sign the paperwork. emt basics can still only do nothing. my suggestion is if your looking for more responsibility be a medic.


 

Ok so if the guy's head is sitting in his lap, you as an emt-b still have to call for a medic to pronounce???

doesn't sound right.

 Basics in NY can pronounce providing it's obvious ( decapitation, Lividity etc.)


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## Raf (Jun 3, 2007)

In MA an EMT-B can declare death if it's dependent lividity, decapitation, or rigor mortis. There's one more..


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## StrokedOut (Jun 3, 2007)

Here it depends on the service and their protocols. A combination of the following must be present for an EMT-A to declare a death:

Rigor
Lividity
Pulseless
Apneic
Pupils F/D
Decapitation
Asystole In 3/3 Leads (We can only do 3 or 4 leads; 12 leads are for EMT-P's)
Obvious Decomp


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## TraumaJunkie (Jun 3, 2007)

Remember your only a basic. When in doubt work the patient. And if available call for ALS or contact medical control.


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## medicdan (Jun 4, 2007)

One other note: I have heard before, in cases of SIDS, it is often in the best interest of the parents (PFA, Psycological First Aid) even if the baby is gone, we make every effort to revive the baby-- so the parents can see something was done.


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## BossyCow (Jun 4, 2007)

As I understand the language on declaring death, an EMT-B can determine field death under the conditions listed above.  These are generally events that occurred prior to our arrival on scene.  We can tell that someone already died, but to make the determination during our care.... that requires the MPD's stamp.  Unless of course, someone's head falls off while we are giving treatment!  Or perhaps they suddenly experience rigor mortis.  

If we show up to a live pt. unless there is a document that meets the legal requirements in effect by your protocols, and be very careful because those criteria differ widely from area to area, we must treat the patient as though they have every chance of surviving the event.


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## StrokedOut (Jun 4, 2007)

TraumaJunkie said:


> Remember your only a basic. When in doubt work the patient. And if available call for ALS or contact medical control.



Were you replying to my post?


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## emt43098 (Jun 11, 2007)

here in mi we have protocols that state we do not have to resuscitate in cases of obvious signs of death and dnr's but we do have to call in a hern and recieve a time of death from the er doc and then call pd and they contact the me and body removal as soon as pd is on scene we are released


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