# Dilemma - CPR on pt. with invalid DNR form



## Shotzman (Jan 10, 2014)

so i was in a situation the other day where we picked up a patient to take to a nursing home... going on hospice care. Family thought he was gonna die that day from his liver cancer but ultimately he hadn't and they expected no more than 72 hours for him to live. His respiration's were labored and rapid and slightly irregular, and his skin had just become jaundiced a couple hours before we arrived. I had put him on 5 liters for the comfort while in my care. Anyways, ultimately, we received the DNR from the family that was signed by the patient... but did not have a physicians signature! we called our supervisor to make sure we couldn't honor it and he told us we  couldn't without the physicians signature  , which we had figured already. On the drive to the nursing home... I sat there thinking to myself, I don't want this guy to die on me and have me work him when he obviously doesn't want to be resuscitated, and how much it sucks that it comes down to a piece of unsigned paper that I have to legally perform CPR on him. And I thought, I could "half-***" the CPR so it works in both parties favors. 
Then I thought, that just seems wrong to ever half-*** CPR no matter the situation. 

Luckily the drive went fine and uneventful. I just wanted to see what others had to say on this type of situation. :sad:


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## Shotzman (Jan 10, 2014)

And I sit here now after typing that wondering if I'm stepping over boundaries thinking that way? Or if bringing up a legal matter up for people to discuss if they'd half *** CPR, am I in the wrong? I'm in a very confused state right now haha if you couldn't tell. I just need opinions on anything on this!


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## MrJones (Jan 10, 2014)

Kentucky further complicates the issue by requiring a separate, specific EMS DNR form. Without it, even in the presence of an otherwise 100% valid DNR form, we are required to perform CPR and such if a patient codes during transport. And we invariably get the deer in the headlights look when a Nurse tells us the patient is DNR and we ask for the signed EMS DNR form.


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## Aprz (Jan 10, 2014)

If the patient has a durable power of attorney, they could say no CPR? Or if the patient goes into cardiac arrest, pull over, start chest compressions, have your partner trade with you, and then call medical direction to tell 'em the situation.


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## TheLocalMedic (Jan 10, 2014)

Hey Shotzman, since you're operating under the Coastal Valleys EMS protocols, check out policy number 7006: Determination of Death in the Prehospital Setting.  Section A, subsection 6 heading a. point 7:

_Resuscitation may be withheld at family request if there is unanimous agreement between all family members on scene. In such a case the EMT or paramedic may choose to consult with Base MD, however the consultation is optional. If there is any doubt or dissention among family or rescuers as to the appropriateness of the decision to withhold resuscitation, resuscitative efforts should continue as per applicable protocol(s).
_
Which can be interpreted to mean:  If all present family members agree that there shall be no resuscitative measures performed (and that can be ascertained before transport, if they are present in the hospital) then should the patient code en route you shall not undertake any kind of resuscitation.  

However, when in doubt, you ought to work that code.  While it does present an ethical dilemma, if there is any doubt about whether or not you should act, begin basic BLS CPR, contact base and an ALS provider and go from there.  You have to protect your own backside, so provide some form of care until you can confirm that you can stop.  

Nobody wants a patient to code during a transfer, but it does happen.  It sounds like your patient was pretty imminent anyhow, so if I were in your shoes and they happened to die en route, I most likely would have not undertaken any kind of resuscitation.  But I'd have made darn sure before leaving that we had already planned for that eventuality and discussed it with the family to verify that they truly didn't want anything done for the patient.


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## TheLocalMedic (Jan 10, 2014)

I've had a few patients code on me during transfers (apparently I'm the Angel of Death), but only one actually had any form of DNR.  The one that did have a POLST form resulted in us simply diverting to the nearest hospital and notifying the coroner to have a LEO meet us at the hospital to take custody of the body.


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## jeepdude911 (Jan 10, 2014)

This is an easy one. Work him. No M.D. signature, no withholding of care. Don't even think about "half ***" CPR.


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## NomadicMedic (Jan 10, 2014)

Or better yet, call your doc on the phone and explain the situation, on a taped line.

Transporting a patient to hospice and working a cardiac arrest on the way is simply ludicrous.

If you believe, by any stretch of the imagination, that working that cardiac arrest while en route to HOSPICE is appropriate in any way, shape or form… Immediately mail your certification back to the agency that issued it and leave EMS.


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## Medic Tim (Jan 10, 2014)

jeepdude911 said:


> This is an easy one. Work him. No M.D. signature, no withholding of care. Don't even think about "half ***" CPR.




This may be true in your area but not everywhere. 

Where I work a DNR does not need to be officially valid for us to honour it. We can also take verbal DNRs from family as long as the request seems reasonable.

Know your state rules and company policies. This situation is most likely covered. As a last resort you can always contact your medical director or Med control.


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## JPINFV (Jan 10, 2014)

TheLocalMedic said:


> Hey Shotzman, since you're operating under the Coastal Valleys EMS protocols, check out policy number 7006: Determination of Death in the Prehospital Setting.  Section A, subsection 6 heading a. point 7:
> 
> _Resuscitation may be withheld at family request if there is unanimous agreement between all family members on scene. In such a case the EMT or paramedic may choose to consult with Base MD, however the consultation is optional. If there is any doubt or dissention among family or rescuers as to the appropriateness of the decision to withhold resuscitation, resuscitative efforts should continue as per applicable protocol(s).
> _



Sweet... so I don't have to look up the protocol for the OP!

I've had cases where hospice patient didn't have a valid DNR and I went down that route prior to transport. Wrote up a quick DNR on the top of the narrative, have the family member sign it (in accordance with OC EMSA protocol), and away we went.


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## joshrunkle35 (Jan 10, 2014)

This is simple: don't make life or death decisions for patients. You're not a doctor. The patient might want to live, yet a family member might want their inheritance, and may have fraudulently signed the DNR. You don't know the details.

Apologize. Explain to family. ALWAYS PROVIDE HIGH QUALITY CPR! (What if a different family member found out about the whole thing, said it was his will to live, and now sues you over your incompetence!) Contact medical control and explain the situation. Let them make the decision. You follow their decision (provided it's within scope), then document that you did it because you're following their decision, not because you made a decision of your own. You're not a doctor! I'm assuming you don't carry millions of dollars in malpractice insurance either. That's why we let doctors make the big decisions.


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## jeepdude911 (Jan 10, 2014)

Medic Tim said:


> This may be true in your area but not everywhere.
> 
> Where I work a DNR does not need to be officially valid for us to honour it. We can also take verbal DNRs from family as long as the request seems reasonable.
> 
> Know your state rules and company policies. This situation is most likely covered. As a last resort you can always contact your medical director or Med control.



This incident took place in CA. If you don't have an MD signature, you don't have a DNR. I know it sounds ridiculous to continue care going to hospice, but legally, in CA we would have to work the patient and proceed to nearest ER or return to originating facility. It sounds like in some areas, these laws are open to interpretation. In CA, they are not, nor are they always reasonable. Even a clean DNR can be invalidated on scene if a family member verbally states for you to intervene. So as you may be a little puzzled to find out, there is almost no such thing as a rock solid DNR in the golden state.


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## Medic Tim (Jan 10, 2014)

joshrunkle35 said:


> This is simple: don't make life or death decisions for patients. You're not a doctor. The patient might want to live, yet a family member might want their inheritance, and may have fraudulently signed the DNR. You don't know the details.
> 
> Apologize. Explain to family. ALWAYS PROVIDE HIGH QUALITY CPR! (What if a different family member found out about the whole thing, said it was his will to live, and now sues you over your incompetence!) Contact medical control and explain the situation. Let them make the decision. You follow their decision (provided it's within scope), then document that you did it because you're following their decision, not because you made a decision of your own. You're not a doctor! I'm assuming you don't carry millions of dollars in malpractice insurance either. That's why we let doctors make the big decisions.




Wow. I don't even know where to start with this one.

It is our job to do what is in the pts best interest. A DNR is a very reasonable request in this instance. End stage ca . You seriously think they family might be trying to off their family member but can't wait a few more hours... ? Give me a break.

Being a protocol monkey and not using critical thinking in conjunction with assessment or evaluation for fear of being sued is ridiculous. Why are you basing your treatment off of old war stories and EMS myth. Can  you give even 1 example of an EMT or medic being successfully sued for following following the pts and family's wish to die in an end stage ca pt?
I understand that there are areas that require physician contact but it does not take a target off our back like you think it does. You will also get much further with docs when you actually sound like you know what you are talking about...like you know what your doing . Ex is requesting specific orders vs... I don't know what to do... Please tell me...( again I understand there are times when this will happen... Probably more often at the BLS level )

As I mentioned before, most companies have policies that cover these situations. It is your responsibility to know your scope, protocols am company policies.


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## Medic Tim (Jan 10, 2014)

jeepdude911 said:


> This incident took place in CA. If you don't have an MD signature, you don't have a DNR. I know it sounds ridiculous to continue care going to hospice, but legally, in CA we would have to work the patient and proceed to nearest ER or return to originating facility.




I believe someone else posted the area in questions policy. Which is different from what you have written above.


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## unleashedfury (Jan 10, 2014)

In that situation I'd call for medical control for further direction

Fact Findings Pt. is being discharged to hospice, Has a DNR prepared not signed by a physician. Family most likely expects the patient to die, Patient may have made the decision already to proceed with hospice care and is expected to die. 

Don't half *** anything that leaves you not only open for legal consequences but questions your capabilities as a provider. explain to the Doc that you have a hospice patient that has a DNR form completed and not signed by a physician, family accepts the fact that CPR is to be withheld and allow him to make the call. 

Or do your job and divert to the closest ED. I have had a Cardiac arrest that was a "DNR" and it wasn't valid, We proceeded with interventions family arrived and talked with the ED after he had ROSC. They extubated him and allow for comfort measures to take place on the med surg floor.


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## joshrunkle35 (Jan 10, 2014)

Medic Tim said:


> Wow. I don't even know where to start with this one.
> 
> It is our job to do what is in the pts best interest. A DNR is a very reasonable request in this instance. End stage ca . You seriously think they family might be trying to off their family member but can't wait a few more hours... ? Give me a break.
> 
> ...




I am being a patient's advocate by using critical thinking and realizing that I don't know the whole situation. I realize that no doctor may have ever explained to the patient what a DNR is (hence, no Dr's signature). The patient may not have understood what they signed. There could be a billion different scenarios here, none of which benefit the patient by me following a half-done DNR. 

Obviously, if you live in a very specific, small portion of the US that has a different protocol, by all means, follow it. 

The reality is not that following what a textbook says to do makes you a "protocol monkey", the reality is that as the patient's advocate, you have to realize that there are dozens of possibilities that this may not be what the patient wants, or that they might not understand what they signed. As a patient's advocate, it is in their best interest for me not to follow an invalid DNR. I do follow the protocol not as a "monkey", but as a well-thought-out solution to a problem that I recognize that I don't have all of the answers to.


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## jeepdude911 (Jan 10, 2014)

Medic Tim said:


> I believe someone else posted the area in questions policy. Which is different from what you have written above.



TheLocalMedic weighed in on this. This medic is from CA. Shotzman is even from an area of CA that I have worked in prior, and the only prudent course of treatment in CA, especially if this was an IFT, meaning dual EMT crew is CPR, AED, lights and siren.


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## mycrofft (Jan 10, 2014)

You're a tech, follow protocols when you can, call for help (MD or supervisor) when you need more. Never treat halfway, that's malpractice and should not be in any protocol (probably isn't).

A resuscitation can always be stopped later. Death…not so much.

PS: the taped phone line thing? Have a second person listen in and identify themselves to the MD; that way you have a witness, and so does the doc.


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## Handsome Robb (Jan 10, 2014)

There's no reason you can't honor this patient's wishes, get a doctor involved. You'd be surprised how understanding the big bad MDs really are. 

I went on a 93 year old female found in cardiac arrest, unknown down time, asystole on the monitor, no "obvious" signs of death, family doesn't want anything done.

Partner does hands only CPR, I call a doc and tell them exactly what I just told you, time of death everyone stop. Easy as that.

Mycrofft, I don't agree with what you just said at all. We are there for the patient's best interest and to be a patient advocate. Not some technician blindly following protocols. That is the EXACT attitude we've been working hard to drive out of EMS, so please don't continue to go spreading misconceptions like that about EMS to our newer providers because when you teach them bad habits it's that much more difficult for us to break them of it and teach them the right way.


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## chaz90 (Jan 10, 2014)

There's not a chance I'm initiating any kind of resuscitation on a pulseless and apneic DNR patient going to hospice. This patient has made his wishes clear, and I'm not going against them. For anyone to stand behind "protocol" and say resuscitation is indicated shows they are entirely too reliant on black and white words on paper and not the gray generalities that are day to day life in medicine and life.


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## Handsome Robb (Jan 10, 2014)

Where's the like button??


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## Medic Tim (Jan 10, 2014)

Robb said:


> Where's the like button??




Agreed


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## Shotzman (Jan 10, 2014)

thanks for the responses everyone.
and thanks for finding that coastal valleys protocol for me, i wouldnt have thought to look for something like that, mainly because i was always taught power of attorney and/or a valid dnr form. 
yes i am very aware that when it all comes down to it, i know i shouldn't start CPR on someone like this mans situation and the situation i was put in, and his familys request to not resuscitate (prior to the knowledge of the verbal unanimous decision of on scene family members), its a moral dilemma, and ultimately it seemed quite obvious that he shouldnt be brought back HAD he coded. the guys mind was gone, alert to painful stimuli only and incomprehensible/inappropriate words (though he was still with it enough to shout "bathroom" and forcibly try and stand up to get to the bathroom, but thats besides the point)  but its quite early in my career and its nerve racking thinking id stray from protocol rather than what I think is necessary to be done ( or not be done technically in this case ). How closely does one need to stay true to protocol in a situation such as this


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## joshrunkle35 (Jan 10, 2014)

chaz90 said:


> There's not a chance I'm initiating any kind of resuscitation on a pulseless and apneic DNR patient going to hospice. This patient has made his wishes clear, and I'm not going against them. For anyone to stand behind "protocol" and say resuscitation is indicated shows they are entirely too reliant on black and white words on paper and not the gray generalities that are day to day life in medicine and life.




They're not a DNR patient. They don't have a valid DNR.

ETA: Someone's life is not a light thing. If they wrote, "Please let me die." on a napkin near their bed, would you do it? Because it's effectively the same thing.


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## chaz90 (Jan 10, 2014)

joshrunkle35 said:


> They're not a DNR patient. They don't have a valid DNR.
> 
> ETA: Someone's life is not a light thing. If they wrote, "Please let me die." on a napkin near their bed, would you do it? Because it's effectively the same thing.



They are a DNR patient! I'd call in to Medical Control and let them know I was withholding CPR, but I would absolutely withhold CPR. Hospice-Check. Terminal Cancer-Check. DNR-Check (excepting the proper physician's signature)-Check.


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## Medic Tim (Jan 10, 2014)

Shotzman said:


> thanks for the responses everyone.
> and thanks for finding that coastal valleys protocol for me, i wouldnt have thought to look for something like that, mainly because i was always taught power of attorney and/or a valid dnr form.
> yes i am very aware that when it all comes down to it, i know i shouldn't start CPR on someone like this mans situation and the situation i was put in, and his familys request to not resuscitate (prior to the knowledge of the verbal unanimous decision of on scene family members), its a moral dilemma, and ultimately it seemed quite obvious that he shouldnt be brought back HAD he coded. the guys mind was gone, alert to painful stimuli only and incomprehensible/inappropriate words (though he was still with it enough to shout "bathroom" and forcibly try and stand up to get to the bathroom, but thats besides the point)  but its quite early in my career and its nerve racking thinking id stray from protocol rather than what I think is necessary to be done ( or not be done technically in this case ). How closely does one need to stay true to protocol in a situation such as this




That will depend on your medical director and location. Where I work we are expected to deviate from our clinical guidelines if it is in the best interest of the pt. we also do not call for orders. We can call a doc to consult a treatment plan we have already formulated. If I had ran a full code on this person the call would have been flagged and I would have been sent for remedial training. 

That is for my area though. It is important to know you company and state policies and to know what is expected of you. This job can be very tough, especially if you are new. I hope you don't think we are all jumping on you here. We are offering some constructive criticism and an outside view.


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## Medic Tim (Jan 10, 2014)

chaz90 said:


> They are a DNR patient! I'd call in to Medical Control and let them know I was withholding CPR, but I would absolutely withhold CPR. Hospice-Check. Terminal Cancer-Check. DNR-Check (excepting the proper physician's signature)-Check.




Maybe this is another regional difference but everywhere I have ever worked... States and Canada. To be accepted into hospice = you had DNR .


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## unleashedfury (Jan 10, 2014)

mycrofft said:


> You're a tech, follow protocols when you can, call for help (MD or supervisor) when you need more. Never treat halfway, that's malpractice and should not be in any protocol (probably isn't).
> 
> A resuscitation can always be stopped later. Death…not so much.
> 
> ...


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## Handsome Robb (Jan 10, 2014)

joshrunkle35 said:


> They're not a DNR patient. They don't have a valid DNR.
> 
> ETA: Someone's life is not a light thing. If they wrote, "Please let me die." on a napkin near their bed, would you do it? Because it's effectively the same thing.




If you really wanna try and argue that let's do it but he's in the process of getting the DNR paperwork done, going home on hospice and family wants nothing done. In a situation like you described with the napkin it's totally different. This patient has a terminal disease process. Let him die the way he wants to. People die, it's part of life. Unfortunately in EMS classes they tend to teach you have to save everyone, which is not the case. Anyone ever though that honoring a patient's last wishes and letting them die rather than resuscitating them and subjecting them to further pain and suffering is actually saving them? I know I have. 

That's a patient you don't start resuscitation on. I have a protocol that if I can't make contact I can do what's in the best interest of the patient, if I couldn't make base contact in this situation I still would pronounce the patient without any resuscitation efforts. 

Now if you do have radio/call service get on the phone with a doc and get orders, OLMC orders are no different than standing orders, provided what is ordered is within your scope of practice. 

Does that answer your question at all, OP?


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## TheLocalMedic (Jan 10, 2014)

I don't know how much clearer I can make this;  *this whole "dilemma" has already been addressed in the area shotzman is working in*.  That stipulation in the region's protocols about terminating resuscitation at the behest of the family was specifically added to circumvent this exact scenario.  

The medical director for CVEMSA, Dr Luoto, has a lot of hospice knowledge and experience, and he would absolutely not advise that this patient be worked.  If someone is in cardiac arrest and the family does not want resuscitation (_especially_ since this is a hospice patient), then you should not even begin.  The existence of the DNR (albeit without an MD signature) and the family's expressed wishes that the patient not be resuscitated (which were expressed before the transfer was made) absolutely spell out that no resuscitation is to take place.  

The protocol does say that you may make base contact, but it is not required.  That's thrown in there just in case you aren't totally confident about the situation, but it is generally understood by anyone with any medical training or experience that there would be no benefit to attempting to "save" this already terminally ill and dying patient.


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## Handsome Robb (Jan 10, 2014)

TheLocalMedic said:


> I don't know how much clearer I can make this;  *this whole "dilemma" has already been addressed in the area shotzman is working in*.  That stipulation in the region's protocols about terminating resuscitation at the behest of the family was specifically added to circumvent this exact scenario.
> 
> 
> 
> ...




I don't think that was directed at me seeing as we agree but just making sure.

I, admittedly, skimmed the thread.

MedicTim: here the only DNR I can honor is a "State of nevada prehospital DNR". Unfortunately hospice =/= valid DNR here. We just released a statewide POLST form so I'm assuming we will be able to honor that as well. 

Even if a hospice patient doesn't have the valid prehospital DNR I don't do anything, call a doc and tell them I've got a hospice patient without a valid DNR in cardiac arrest, I haven't started resuscitation and request a time of death. Never had a problem with it, including a 15 year old with end stage ovarian cancer. Took a minute for the doc to understand what I was saying but he didn't have an issue with how I handled it.


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## TheLocalMedic (Jan 10, 2014)

Robb said:


> I don't think that was directed at me seeing as we agree but just making sure.
> 
> I, admittedly, skimmed the thread.
> 
> ...



No, wasn't directed at you, it sounds like we're on the same page.  It was directed at anyone who was saying that we have an obligation to work a code if there isn't a black and white DNR on hand.  

Medicine isn't always black and white, but it's still safe to say that a terminal patient shouldn't get worked.  Now, on the other hand, if you run into a situation where there isn't a DNR and you have family urging you to act, then your best bet is to at least begin BLS CPR until you can get a physician on a recorded line giving you permission to stop.  

But generally speaking people will understand that their terminally ill family member was going to die soon (even though they were hoping for more time) and an honest conversation with them about the futility of attempting resuscitation may be all that is needed for them to agree that any resuscitation should be terminated.  

And just to throw this tidbit in:  one of the best pieces of advice I was given was 'people who are kind, caring and compassionate don't get sued'.  And it's pretty true.  So don't be an authoritative a-hole and arrogantly refuse to resuscitate someone.  Instead have a calm, sit-down conversation with the family about the reality of the situation and explain in simple terms what is going on.  Even if you were in the right about not working the code, if you sound like a jerk it'll cause resentment and you could wind up with people throwing accusations at you.


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## mycrofft (Jan 10, 2014)

unleashedfury said:


> mycrofft said:
> 
> 
> > You're a tech, follow protocols when you can, call for help (MD or supervisor) when you need more. Never treat halfway, that's malpractice and should not be in any protocol (probably isn't).
> ...


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## mycrofft (Jan 10, 2014)

Doesn't the whole thrust of this thread boil down to "Does it require a MD's signature to make a DNR kosher, or can a patient simply convey their wishes?" ?


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## NomadicMedic (Jan 10, 2014)

No. It boils down to the transporting EMS provider using common sense and preparing for the situation.


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## triemal04 (Jan 10, 2014)

TheLocalMedic said:


> Medicine isn't always black and white, but it's still safe to say that a terminal patient shouldn't get worked.  Now, on the other hand, if you run into a situation where there isn't a DNR and you have family urging you to act, then your best bet is to at least begin BLS CPR until you can get a physician on a recorded line giving you permission to stop.
> 
> *But generally speaking people will understand that their terminally ill family member was going to die soon (*even though they were hoping for more time) and an honest conversation with them about the futility of attempting resuscitation may be all that is needed for them to agree that any resuscitation should be terminated.
> 
> And just to throw this tidbit in:  one of the best pieces of advice I was given was 'people who are kind, caring and compassionate don't get sued'.


I like it that the part of Cali' that you are in has this issue covered; I really, really like that in fact.  Unfortunately, many places don't have explicit instructions on what to do in this type of situation, so it still falls to the provider.  People just need to remember that someone dying is not always a bad thing, and that often starting a resuscitation would go against what both the patient, and family would want.  In essence:  if you can't technically withhold CPR but common sense and the family is saying to stop...get ahold of your medical control ASAP.  Death is not some big bad terrible foe that we are supposed to be up against, despite what get's taught in to many places.  People die.  Simple fact of life.  Often it is better to leave them be.

The bolded part:  be careful with that.  As the recent freakshow (leach show) from California shows, not everyone feels that way.  This is something that needs to be taken on a case by case basis; if the family is ok with not starting a resuscitation that's one thing...but if they aren't and are very opposed to not doing so AND you don't have protocols in place to address this, the situation is different.  Calling medical control is still an option, talking honestly with the family is still an option, and something that should be done, but in the interest of your continued career, you may be out of options.  Just something to be aware of.

The last part:  fortunately, and unfortunately, very true.


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## Shotzman (Jan 10, 2014)

Yes, at least for California's CVEMSA protocols I'm definitely understanding now. This has definitely put my mind at ease if this situation is to arise again. Thank you! In school we are only taught "no valid dnr? Do CPR. No valid power of attorney? Do CPR" no if's and's or but's, so like I said, I never thought to look that closely at the protocols or that it would have something to say like you brought up LocalMedic! And I didn't think base MD could pronounce someone dead from over the phone and allow you to cease CPR. 
Sounds like other states aren't the same, hence the different opinions.


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## Rialaigh (Jan 10, 2014)

What more is a DNR then a legally binding way for a patient to communicate what he or she wants. If they lack a DNR then you use family, what you know about the patient and history, and make a judgement decision on what you think the patient would have wanted.

You do not have to have a DNR to not provide treatment. You only have to have a firm belief that the patient (and family in most states) does not want anything done. 

This is the same thing as the patient refusing transport that you think is having a STEMI. So you wait until he becomes unconscious and then you treat and transport....it should be criminal. The patient, while coherent and oriented made a decision about his or her medical care. Don't use "altered mental status" or "unresponsive" as an excuse to play god and do everything for the patient.


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## Rialaigh (Jan 10, 2014)

mycrofft said:


> Doesn't the whole thrust of this thread boil down to "Does it require a MD's signature to make a DNR kosher, or can a patient simply convey their wishes?" ?



And to address this, doesn't the patient convey their wishes all the time about whether they want to be transported or want meds or etc..etc..

In this situation if I heard the patient verbally say to me he didn't want anything done then I don't care if I have a DNR or not...The patient stated his wishes on a medical matter and (especially) if the family is agreeing who am I to play god and provide unwanted treatment and make medical decisions for someone else.


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## Handsome Robb (Jan 10, 2014)

Agreed on all points!


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## mycrofft (Jan 10, 2014)

DEmedic said:


> No. It boils down to the transporting EMS provider using common sense and preparing for the situation.



Sure.


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## triemal04 (Jan 10, 2014)

Rialaigh said:


> This is the same thing as the patient refusing transport that you think is having a STEMI. So you wait until he becomes unconscious and then you treat and transport....it should be criminal. The patient, while coherent and oriented made a decision about his or her medical care. Don't use "altered mental status" or "unresponsive" as an excuse to play god and do everything for the patient.


It's funny...I used this hypothetical scenario on another EMS website; what are you going to do when you attempt to treat the patient who, after being informed of the risks and adamantly refuses treatment, becomes unresponsive, and the family begins to scream at you to not touch them?

About the only response I got was the sound of crickets...

People really need to think about this and be ready for it.


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## Handsome Robb (Jan 10, 2014)

mycrofft said:


> Doesn't the whole thrust of this thread boil down to "Does it require a MD's signature to make a DNR kosher, or can a patient simply convey their wishes?" ?




Is that not exactly what we are all talking about?


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## mycrofft (Jan 10, 2014)

Robb said:


> Is that not exactly what we are all talking about?



I thought so. But I've certainly been wrong before.

Probably will be again tomorrow before supper.


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## TheLocalMedic (Jan 10, 2014)

Robb said:


> Is that not exactly what we are all talking about?



I think it's more along the lines of the being given an incomplete DNR without an MD signature and having a patient who isn't really coherent enough to ask directly.  Honestly though, if the family says "no code", then that's what I'm going to do, regardless of whether or not the DNR isn't tip-top.


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## Handsome Robb (Jan 11, 2014)

TheLocalMedic said:


> I think it's more along the lines of the being given an incomplete DNR without an MD signature and having a patient who isn't really coherent enough to ask directly.  Honestly though, if the family says "no code", then that's what I'm going to do, regardless of whether or not the DNR isn't tip-top.




I definitely agree. I'm not fighting with a family and working a code.


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## mycrofft (Jan 13, 2014)

TheLocalMedic said:


> I think it's more along the lines of the being given an incomplete DNR without an MD signature and having a patient who isn't really coherent enough to ask directly.  Honestly though, if the family says "no code", then that's what I'm going to do, regardless of whether or not the DNR isn't tip-top.



I'll drink to that.:beerchug:


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## yowzer (Jan 13, 2014)

My protocols would let us withhold resuscitation attempts in that case, valid DNR/POLST or not. If a patient has a terminal illness and family doesn't want anything done, we're supposed to respect their wishes.


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## CentralCalEMT (Jan 14, 2014)

jeepdude911 said:


> This incident took place in CA. If you don't have an MD signature, you don't have a DNR. I know it sounds ridiculous to continue care going to hospice, but legally, in CA we would have to work the patient and proceed to nearest ER or return to originating facility. It sounds like in some areas, these laws are open to interpretation. In CA, they are not, nor are they always reasonable. Even a clean DNR can be invalidated on scene if a family member verbally states for you to intervene. So as you may be a little puzzled to find out, there is almost no such thing as a rock solid DNR in the golden state.



While that might be true in a lot of places, remember CA lets EMS be run at the local (county or combined county) level. State EMS guidelines are just that, guidelines and individual counties run things differently. 

It's amazing how even in the same state, and yes I am aware this is crazy CA, protocols can differ greatly between EMS administrative areas. Where I work, which is part of the 4 county CCEMSA system, we have broad definitions of what a DNR is. There is even a guideline that states a DNR "may or may not be signed by a physician." We can accept internal DNRs from long term care facilities as long as they are short and to the point. We can accept "Do not resuscitate" written by a MD in a patient's chart as a physician order as well as other commonly accepted forms. We can also accept DNR medallions and even oral DNRs from the patient before they code or the immediate family members over 18 if they are involved in direct patient care. (That way a long lost cousin cant resurface and try and  get CPR withheld) Personally, I believe these guidelines are ethical and put the desires of the patient first. Having all these guidelines I personally believe maintains a patient's dignity. Of course any and all of these can be revoked by a patient, caregiver, family member or base hospital MD at any time. 

I would feel horrible initiating ACLS measures or even BLS on a hospice patient because of paperwork confusion. In 2014 any EMS administration that does not address with some detail DNR/advanced directives and take into account all the circumstances might be behind the times.


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## Handsome Robb (Jan 14, 2014)

I'm gonna say it again. Pick up a freaking telephone or turn in your patch.

I'm done being nice about it and listening to people advocate for violating a person's last and final wishes in regards to their healthcare and remains.

We are patient advocates. Patient advocates *do what they have to to provide what is best for the patient and to honor their decisions in regards to their healthcare.*


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## Kevinf (Jan 14, 2014)

What I'd like to know is why it's so difficult to fill out a half-page form properly. Without hyperbole, roughly 80% of the DNR forms I receive are not valid for one reason or another. They aren't that complex! This is coming from hospice, hospitals, and ECFs... they should know how to fill one out.

Legally, it's not a bad idea to have your paperwork in order before transporting a patient from a care facility... I.e. transfer of care signature, signed for any of the patient's narcotics, valid DNR, etc. Going to agree that you really shouldn't be doing CPR on a terminal patient. It would just be nice if we got proper forms once in awhile.


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## Handsome Robb (Jan 14, 2014)

Kevinf said:


> What I'd like to know is why it's so difficult to fill out a half-page form properly. Without hyperbole, roughly 80% of the DNR forms I receive are not valid for one reason or another. They aren't that complex! This is coming from hospice, hospitals, and ECFs... they should know how to fill one out.
> 
> Legally, it's not a bad idea to have your paperwork in order before transporting a patient from a care facility... I.e. transfer of care signature, signed for any of the patient's narcotics, valid DNR, etc. Going to agree that you really shouldn't be doing CPR on a terminal patient. It would just be nice if we got proper forms once in awhile.




I agree, there's no argument there.

However the lack of a valid DNR can be *easily* circumvented. 

Unfortunately calling for orders seems to have this stigma of "you don't know what you're doing." People at my agency brag about not ever calling, which per protocol we rarely have to. I call all the time to go around my protocols to provide appropriate and compassionate care just like is hope someone would do for me, my family or my friends.


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## Akulahawk (Jan 14, 2014)

Robb said:


> I agree, there's no argument there.
> 
> However the lack of a valid DNR can be *easily* circumvented.
> 
> Unfortunately calling for orders seems to have this stigma of "you don't know what you're doing." People at my agency brag about not ever calling, which per protocol we rarely have to. I call all the time to go around my protocols to provide appropriate and compassionate care just like is hope someone would do for me, my family or my friends.


If I'm calling for orders, it's going to be for the reason above (get around an invalid DNR), to create a custom care plan for a patient that doesn't fit any protocol that we have, or to be able to go past a particular pre-determined point in a given protocol. Our transports are usually so short that we almost NEVER had to call for base orders to go beyond that big black line...


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## Handsome Robb (Jan 14, 2014)

Akulahawk said:


> If I'm calling for orders, it's going to be for the reason above (get around an invalid DNR), to create a custom care plan for a patient that doesn't fit any protocol that we have, or to be able to go past a particular pre-determined point in a given protocol. Our transports are usually so short that we almost NEVER had to call for base orders to go beyond that big black line...




Agreed. My transport times are generally <10 minutes but in a situation like you described, with a patient that doesn't fit into a protocol, it's not a big deal to start the ball in motion, delegate things then call while your partner and fire packages and loads the patient.

Maybe I didn't articulate what I meant very well.


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## SandpitMedic (Jan 14, 2014)

My local protocol:


> DO NOT RESUSCITATE
> 
> 1. All patients with absent vital signs who do not have conclusive signs of death (refer to Prehospital Death Determination protocol) shall be treated with life-resuscitating measures unless EMS personnel are presented with a valid Do-Not Resuscitate (DNR) Identification or Order.
> 
> ...


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## SandpitMedic (Jan 14, 2014)

You see my protocols. I'm pretty much covered. Even subsection 7 says if I'm unwilling or unable to comply with the DNR to transfer them to a facility/provider that will/can. 

Now, I side with Robb. With all things considered: No way am I going to start resuscitation on an end stage ca patient who was given 72 hours to live with a partial DNR and family agreeing to withhold. HOWEVER, before that patient is on my gurney that paper is getting signed by a physician. I will avoid the issue by solving it right there. MD at the facility, fax it, or whatever- I'm getting it signed or I am calling for OLMC and explaining the situation and documenting an OLMC MD order to withhold in the event of cardiac arrest on the Protocol Deviation form we are provided and in my chart. What's the 15 minutes it takes to get that done? There's no reason to load and go. Get it taken care of before you transport. Problem solved. Protocol deviation forms are available for those grey areas... It's expected for you to do what is in your patients best interests- always.

Now as we've clearly displayed, there are different protocols in different places. Follow them, or contact medical direction. Families and such may not be so "ready" when their loved one actually stops breathing, and may become unpredictable and/or irrational. Or they may claim they weren't in the proper state of mind due to emotional distress. And you're the professional paramedic in the room who has to do something and is expected to act to save a life (clearly to the lay person)... Better think quick. Lets not forget- this is CA we are talking about. You could get sued regardless, and you probably will if things go even a hint towards the sour side. Even if you are innocent or found to be acting in the pt's best interests and not negligently you're going to go bankrupt defending yourself possibly. It's unlikely to reach that level, but you don't want to be on CNN. This is a HOT topic recently, in CA, TX, and elsewhere, and if you follow the news you'll see there are a few of these similar cases going on right now.

Again, this is California were talking about. The state that brought you this little case- remember: http://thelegalguardian.com/good-samaritanism-died-in-a-car-crash/

In case you forgot, a  lay person friend helped rescue a victim from a (supposedly smoking/smoldering) car wreck causing her to be permanently paralyzed... And was sued... And lost in the CA Supreme Kangaroo Court because the Good Samaritan law is for Emergency MEDICAL Care, not to include "rescuing" with the word "medical."

I know that has nothing to do with EMS or the OP's topic, but it brings to helm the ridiculousness of the CA legal system. Regardless of local law/protocol; now put an EMT or Parmedic in those shoes in our "dilemma" and wham-o. The daughter, not on scene was stuck in traffic, did t get to say goodbye, and now shes calling "channel 3 on your side." Instant headlines and legal pundits who know nothing about what it's like to care for a dying patient or a grieving family or to be placed in that position of having to choose to begin CPR or deny CPR are now Monday morning quarterbacking your play, and likely every play you've ever made. Effectively ruining your name and career. You'll have supporters and opposition, but in CA it's a toss up between evil lawyers and common sense deciding your fate. 

Just, ew. What an icky scenario. That will go down differently in any given jurisdiction. Your best bet is to always do what's best for your patient, and always cover your butt at the same time. Get it taken care of before transporting, and keep your name out of the spotlight. Just avoid all that rambling I just did becoming your reality.

OP, lucky for you, it went smoothly.If it had, local protocols backed you, and the family was "normal."


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## SandpitMedic (Jan 14, 2014)

Then you have a case like this:

http://www.theledger.com/article/20130411/NEWS/304115037#gsc.tab=0

Granted, not the same exact scenario, but DNR related. No DNR form (valid or not) and care was intiated, and now people are getting sued. I didn't see EMS getting sued though, because they likely followed protocol and worked the patient despite her being a (allegedly) known DNR at the facility she was picked up from.


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## SandpitMedic (Jan 14, 2014)

Another perfect, and more closely related example. How much do you think this doc's legal fees amounted to? Probably more than you'll make in 10 years as a paramedic considering this case went all the way to trial. Perfect example of the family doing an about-face when the moment arises, and sueing the bejesus out of you. Even after expressed verbal AND documented consent by the patient AND family.

http://www.renalandurologynews.com/...ng-a-do-not-resuscitate-order/article/273249/

The article:


> Dr. L, 45, a pulmonologist, was summoned to a hospital emergency department (ED) because of the severity of a particular case. The patient, Mr. Y, 78, was suffering shortness of breath.
> 
> He also had a long list of serious medical conditions, including a recent intracranial hemorrhage. A computed tomography scan revealed massive blood clotting in Mr. Y's lungs, affecting the flow of blood to his left leg. The scan also showed congestive heart failure. Dr. L determined that the only option was surgical, but the patient's odds were poor.
> 
> ...


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## mycrofft (Jan 14, 2014)

SandpitMedic said:


> You see my protocols. I'm pretty much covered. Even subsection 7 says if I'm unwilling or unable to comply with the DNR to transfer them to a facility/provider that will/can.
> 
> Now, I side with Robb. With all things considered: No way am I going to start resuscitation on an end stage ca patient who was given 72 hours to live with a partial DNR and family agreeing to withhold. HOWEVER, before that patient is on my gurney that paper is getting signed by a physician. I will avoid the issue by solving it right there. MD at the facility, fax it, or whatever- I'm getting it signed or I am calling for OLMC and explaining the situation and documenting an OLMC MD order to withhold in the event of cardiac arrest on the Protocol Deviation form we are provided and in my chart. What's the 15 minutes it takes to get that done? There's no reason to load and go. Get it taken care of before you transport. Problem solved. Protocol deviation forms are available for those grey areas... It's expected for you to do what is in your patients best interests- always.
> 
> ...



Within _months_ of that second appeal (the initial finding was in favor of the defendant, but she lost the two appeals) the state legislature passed language making associated necessary actions part of a GOod Sam's actions, meeting the same criteria for being correct, within training or knowledge, for free, etc.
Rest of reply: you betcha.

Want to hear about messed up legal? On-call medical examiner declared an execution style shooting a suicide in Nebraska once, per my boss.


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## SandpitMedic (Jan 16, 2014)

You never know. Our industry is ripe with lawsuits and a lot of liability.


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## RebelAngel (Jan 16, 2014)

I looked up NYS policy on DNRs because of this thread. I am not sure if it's been posted already but in case it hasn't here it is:
http://www.health.ny.gov/professionals/ems/policy/99-10.htm


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## Fire51 (Jan 16, 2014)

I agree with what people are saying about respecting the patients/famlies wishes about not doing CPR when thier heart stops, but one question I had was, does the receiving hospital still take the patient when they are dead? Especially when you call for a time of death?  I didn't read all 60 or so replies so if it has already been answered I am sorry.


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## TheLocalMedic (Jan 17, 2014)

Fire51 said:


> I agree with what people are saying about respecting the patients/famlies wishes about not doing CPR when thier heart stops, but one question I had was, does the receiving hospital still take the patient when they are dead? Especially when you call for a time of death?  I didn't read all 60 or so replies so if it has already been answered I am sorry.



If you call it in the field, then you call law enforcement.  They'll get the coroner involved and take it from there.  We don't transport dead bodies to the hospital (despite what Hollywood says). 

If you call it en route (uncommon but had it happen for me once on a long rural transport), our policy is to transport non-emergently to the nearest ED and contact law enforcement.  Hospitals have morgues to keep the body until the coroner comes to collect it.


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## ZombieEMT (Jan 17, 2014)

TheLocalMedic said:


> If you call it in the field, then you call law enforcement.  They'll get the coroner involved and take it from there.  We don't transport dead bodies to the hospital (despite what Hollywood says).
> 
> If you call it en route (uncommon but had it happen for me once on a long rural transport), our policy is to transport non-emergently to the nearest ED and contact law enforcement.  Hospitals have morgues to keep the body until the coroner comes to collect it.



Some hospitals do have morgues. Some do not.


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## Fire51 (Jan 17, 2014)

TheLocalMedic said:


> If you call it in the field, then you call law enforcement.  They'll get the coroner involved and take it from there.  We don't transport dead bodies to the hospital (despite what Hollywood says).
> 
> If you call it en route (uncommon but had it happen for me once on a long rural transport), our policy is to transport non-emergently to the nearest ED and contact law enforcement.  Hospitals have morgues to keep the body until the coroner comes to collect it.



Should have specified more. I meant in back of the ambulance, not on scene. Thanks for the answers. Calling for time of death in back of ambulance is rare so I was just wondering what happens when you do.


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## TheLocalMedic (Jan 17, 2014)

ZombieEMT said:


> Some hospitals do have morgues. Some do not.



Even if they don't have a morgue, they've got somewhere they can stash a body.  Like the cafeteria!  They've got freezers in there, right?


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## ZombieEMT (Jan 17, 2014)

Normally when the hospital does not have a morgue, the patient's bed u s where he or she stays, until removed by coroner,  wasting viable space.


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## TheLocalMedic (Jan 17, 2014)

TheLocalMedic said:


> If you call it en route (uncommon but had it happen for me once on a long rural transport), our policy is to transport non-emergently to the nearest ED and contact law enforcement.  Hospitals have morgues to keep the body until the coroner comes to collect it.



I felt that I had to add that I actually needed to look up what the protocol was for terminating a code during transport.  It was an unusual situation and I doubt it will happen again in my career.


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## JPINFV (Jan 17, 2014)

TheLocalMedic said:


> Even if they don't have a morgue, they've got somewhere they can stash a body.  Like the cafeteria!  They've got freezers in there, right?




The decon room in the ED... (and I'm only half joking... but when it's only a couple hours waiting for the coroner to show up...).


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