# DNR's And BLS: HELP! (Los Angeles County)



## ThePsilocybeVibe (Jul 8, 2010)

Hello out there!

This is a long one for those of us in Los Angeles County. This is something we all do everyday and yet it's amazing how many different answers I've received from coworkers and folks from other companies. Scary, really.

At risk of oversimplifying what we do as EMT-1's in LA County, our job is to make sure our PT's get the appropriate level of care according to our assessment. Break ur toe, BLS. Break your skull, probably ALS. Stable vital sign trends, BLS. Vitals that look like 3 different Lotto tickets, ALS.

Right? Simple.

"What's the Effing Scenario?!" u ask? Well... 

U arrive for a transport from Skilled Negligence Facility to an ER an hour away. RN reports PT has Athlete Vitals...120/80, yadda yadda...But u assess at bedside and find PT's vitals are...Well I won't waste ur time...Lets just say they're unstable as all hell with an obvious altered mental status that daughter says is absolutely abnormal. She's usually talking but now she's mumbling 'bout Lucy In The Sky With Diamonds.

ALS? Yep, I'd say so. But remember that DNR?

Question: According to LA County protocols, does a valid DNR order allow the EMT-1 to transport an unstable patient? I ask this because my company (I'm positive it ain't the only company doing this) suspended my partner and I for refusing this transport, pending investigation. I'm losing money 'cause they felt they're losing theirs. My field ops supervisor literally told us that a DNR means "transport anyone, anytime, anywhere"...It's scary because half the EMT's I asked said they agree...The reasoning being "they're gonna die anyway. All u have to do on this transport is sit there."

It absolutely BLOWS MY MIND how some of us think. My understanding is that a DNR is only a piece of paper UNTIL respirations cease or pulse disappears. Up until THAT POINT, the patient is still a living, breathing human being that deserves the best treatment we can offer. Hell...Some of my coworkers told me DNR's dont need oxygen! Scary as hell. I dunno...Correct me if I'm wrong but a DNR is not license to do whatever the heck u want because "they're gonna die anyway."

Here are LA County's EMS Protocols:

http://ems.dhs.lacounty.gov/policies/Ref800/Ref800.htm

Specifically DNR's: http://ems.dhs.lacounty.gov/policies/Ref800/815.pdf

I find no language that demonstrates that a DNR affects transport decisions in any way until a PT's respirations, pulse, or both cease.


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## Shishkabob (Jul 8, 2010)

DNR just means no life saving measures once cardiac compromise sets in, be it CPR, cardioversion, pacing, advanced airway and artificial ventilations.


It has NOTHING to do with transporting, has NOTHING to do with palliative care, and has NOTHING to do with most BLS procedures.


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## JPINFV (Jul 8, 2010)

ThePsilocybeVibe said:


> U arrive for a transport from Skilled Negligence Facility to an ER an hour away. RN reports PT has Athlete Vitals...120/80, yadda yadda...But u assess at bedside and find PT's vitals are...Well I won't waste ur time...Lets just say they're unstable as all hell with an obvious altered mental status that daughter says is absolutely abnormal. She's usually talking but now she's mumbling 'bout Lucy In The Sky With Diamonds.


It takes all of 10 seconds to write the vital signs, what were they? Different people are going to define "unstable as all hell" at different numbers. 



> ALS? Yep, I'd say so. But remember that DNR?
> 
> Question: According to LA County protocols, does a valid DNR order allow the EMT-1 to transport an unstable patient? I ask this because my company (I'm positive it ain't the only company doing this) suspended my partner and I for refusing this transport, pending investigation. I'm losing money 'cause they felt they're losing theirs. My field ops supervisor literally told us that a DNR means "transport anyone, anytime, anywhere"...It's scary because half the EMT's I asked said they agree...The reasoning being "they're gonna die anyway. All u have to do on this transport is sit there."



It really depends on the how and why that they're unstable. If it looks like a disease is taking it's natural course of events, then I agree to go ahead and transport. If it appears to be an acute or new event, then I'd treat like every other patient while following any specific DNR instructions available (which at the EMT level only really comes into play in full arrests). The classic example found on just about all DNRs is that if the patient isn't breathing, then it isn't going to be treated (natural course of events) with the exception of foreign body airway obstructions (acute event) short of the FBAO  leading to respiratory arrest.

I'll give another example. 90 year old patient with neurodegenerative diseases has a DNR and over the past 30 days has been declining. A month ago the patient was talking and now the patient is barely arousable. Is the patient altered compared to a month ago? Yes. However pending other acute changes (including anything short of drastic *deviations* in vital signs) I agree with the "anywhere anytime" philosophy. Getting the patient to the home hospital is what's important. In contrast, a 90 y/o patient with a DNR who's normally sharp as a tack, has a history of diabetes and is now altered is going to be a diabetic emergency until proven otherwise (excuse me, RN. Is there any chance you can get an updated blood glucose level for the hospital while we prepare to package and transport? Thanks!). If I have an altered hypoglycemic patient, then I'm either transporting emergently or calling paramedics because this is an acute and reversible event. In fact, the only acute and reversible event I can think of that wouldn't be treated like this is an opioid overdose, which is again, normally spelled out in the DNR (normally something along the lines of 'Pain medication even if it shortens the patient's life').

As far as being suspended, I agree with the suspension. If you think that the patient was suffering an acute event that needed a paramedic response then you should have picked up the phone, dialed 911, and the conversation should have gone like this,
"Hello, 911, what is your emergency?"
"Good afternoon, this is a XYZ Ambulance Company requesting a paramedic response for one of our patients" 
[give chief complaint, confirm location, get paramedic ETA, and try to meet them at your ambulance]. 

You aren't refusing the patient, but upgrading the patient to an appropriate level of care. If the fire fighters complain, tell them to go pound sand in a diplomatic fashion. 




> It absolutely BLOWS MY MIND how some of us think. My understanding is that a DNR is only a piece of paper UNTIL respirations cease or pulse disappears. Up until THAT POINT, the patient is still a living, breathing human being that deserves the best treatment we can offer. Hell...Some of my coworkers told me DNR's dont need oxygen! Scary as hell. I dunno...Correct me if I'm wrong but a DNR is not license to do whatever the heck u want because "they're gonna die anyway."



I'd argue that a DNR does a little more than not matter until the patient is in arrest. At higher levels, it can very well limit which medications can and can't be given or other interventions (i.e. most DNRs are also "Do Not Intubate" orders. Most of the time they include limits on mechanical ventilation, which can be taken to include PPV. It's my understanding that interventions like CPAP are a gray zone because it's mechanical, yet not what is generally thought of in the sense of a ventilator). As I said earlier, if possible, I'd try to get a patient to their home hospital instead of the closest. Of course each situation is different because what's important is the totality of the situation and not any singe data point. 

As far as supplemental oxygen. On one hand, EMS has a fetish for supplemental oxygen as some sort of cure-all. However, again, just about every DNR I've ever seen has considered supplemental oxygen as a comfort care treatment. As such, if the patient needed supplemental oxygen, by all means administer it. However, just like all patients, I wouldn't administer supplemental oxygen just because I can.


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## JPINFV (Jul 8, 2010)

Linuss said:


> *It has NOTHING to do with transporting*, has NOTHING to do with palliative care, and has NOTHING to do with most BLS procedures.



So if you have an end of life patient with a duly completed DNR order, the patient in what appears to be nearing the end of the natural course of events for that disease process, and the patient's home hospital was 10 minutes further than the closest emergency department, would you reroute?


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## Shishkabob (Jul 8, 2010)

JPINFV said:


> So if you have an end of life patient with a duly completed DNR order, the patient in what appears to be nearing the end of the natural course of events for that disease process, and the patient's home hospital was 10 minutes further than the closest emergency department, would you reroute?



You're thinking of something different than what I was commenting on.

A DNR does not preclude someone from being transported.  Transporting is not, in the eyes of a DNR order, an invasive life saving intervention, and as such just because they have a DNR doesn't mean you can refuse to transport, such as what the OP stated he did.


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## JPINFV (Jul 8, 2010)

Linuss said:


> You're thinking of something different than what I was commenting on.
> 
> A DNR does not preclude someone from being transported.  Transporting is not, in the eyes of a DNR order, an invasive life saving intervention, and as such just because they have a DNR doesn't mean you can refuse to transport, such as what the OP stated he did.



Gotcha.


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## exodus (Jul 8, 2010)

So if the PT is DNR and "we cant do anything to them" why would they go to the ER? They *obviously* want / need something done to them. What if their BP is dropped hella low, or they're tachy? Fluid bolus, maybe dope, seems within the scope of a DNR doesn't it? You're not restarting the heart or doing compressions are you?


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## JPINFV (Jul 8, 2010)

Just because "we can't do anything [for] them" doesn't mean that the hospital can't do anything for them, even if it's just better palliative care than will be received at home hospice or in a SNF. Fluid I can definitely see as an option. I'm not enitrely sure about dopamine though. Remember, what the patient wants in end of life patients is more important than what the patient needs.


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## ThePsilocybeVibe (Jul 8, 2010)

Linuss said:


> You're thinking of something different than what I was commenting on.
> 
> A DNR does not preclude someone from being transported.  Transporting is not, in the eyes of a DNR order, an invasive life saving intervention, and as such just because they have a DNR doesn't mean you can refuse to transport, such as what the OP stated he did.



I didn't refuse transport BECAUSE the patient had a DNR. I refused to take the patient because we are a BLS crew and the PT obviously needed a higher level of care.


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## jjesusfreak01 (Jul 8, 2010)

Maybe request an ALS intercept, transport, and then transfer to ALS along the way. As a general rule, you don't delay care or transport to wait for a higher level of care, be that an ALS truck, a paramedic follow car, or a helicopter.


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## JPINFV (Jul 8, 2010)

General rules don't apply to LA County and Orange County emergency medical systems. In these systems you do wait, however if done properly (i.e. call as soon as you realize you need paramedics. I've gone and called paramedics after seeing my patient at the door to his/her room. While calling and waiting for paramedics, your partner and you (you don't need 2 people to go call for paramedics) assess, begin treatment, package, and move the patient to your ambulance. By that time, paramedics are close enough that there's no need to start transport), you aren't really waiting for long anyways.


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## ExpatMedic0 (Jul 8, 2010)

Correct me if I am wrong here but some DNR's have certain boxes checked that say some procedures are ok to do and others are not. For example, comfort measures only, no IV fluids or meds, or ET tubes, or nothing at all.

If the DNR was filled out in such a way that nothing ALS could be done anyway, I would say BLS transport.

If the DNR was filled out in such a way that anything could be done outside of BLS, ALS transport.

But your a BLS unit and also have protocols to call ALS under certain circumstances. 

Unfortunately it does not sound so black and white. I would bring this problem up to your supervisor or medical director just to make sure. Maybe have some kind of company policy or protocol developed to really spell this out for you guys black and white for situations that people are giving you conflicting answers on.


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## Shishkabob (Jul 8, 2010)

ThePsilocybeVibe said:


> I didn't refuse transport BECAUSE the patient had a DNR. I refused to take the patient because we are a BLS crew and the PT obviously needed a higher level of care.



I hate that cop out. 


If you are closer to an ER than a paramedic is to you, haul butt to the ER.  There is no other proper answer.  Heck, even if paramedics are close, start moving towards the ER and meet them.



Hell, I AM a paramedic and I still realize when things are way out of my realm of control even with my liberal protocols and still haul butt to the ER rather than play with all my fancy skills and toys.  Happened just 3 weeks ago.


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## cristianb36 (Jul 28, 2010)

If you think they will crash on you then package them up and depending on ur eta to the closest transport, don't delay tx just to get paramedics there, take em there urself. My company has tiold me to keep going to destination if its a dnr that dies...I think that's ridiculous. I've rerouted a dnr to a closest er, and lo and behold we hear from family that indeed their loved one was treated with antibiotics and has had an extended life because we didn't just keep going. Company was initially pissed because the snf cAlled angrily because of our reroute, but gave us a bonus later for making the right call. If they fire you for making the right call move on. Plenty of companies out here. Which company is this btw if u don't mind saying


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## Aidey (Jul 28, 2010)

Linuss said:


> A DNR does not preclude someone from being transported.  Transporting is not, in the eyes of a DNR order, an invasive life saving intervention, and as such just because they have a DNR doesn't mean you can refuse to transport, such as what the OP stated he did.



I would say that completely depends on the DNR and exactly what it says. I've seen patients (hospice usually) who have orders that they not be transported unless they have comfort needs that can't be met. Or to call their doctor before transporting. 

An issue I have run into with these patients is family members or staff notice that something is wrong, and demand the patient is transported, even if they are not in any discomfort. We get them to the hospital, and the first thing out of the doctor's mouth is "And what exactly do they want us to do?".  



schulz said:


> Correct me if I am wrong here but some DNR's have certain boxes checked that say some procedures are ok to do and others are not. For example, comfort measures only, no IV fluids or meds, or ET tubes, or nothing at all.



You are correct. I think those only exist in some states though, so it is one of those "depends on local protocols" situations. I know there are some states that have a bare bones DNR, and the state issued DNR is the only one valid out of hospital.


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## CAOX3 (Jul 29, 2010)

ThePsilocybeVibe said:


> Question: According to LA County protocols, does a valid DNR order allow the EMT-1 to transport an unstable patient? I ask this because my company (I'm positive it ain't the only company doing this) *suspended my partner and I for refusing this transport, pending investigation*. I'm losing money 'cause they felt they're losing theirs. My field ops supervisor literally told us that a DNR means "transport anyone, anytime, anywhere"...It's scary because half the EMT's I asked said they agree...The reasoning being "they're gonna die anyway. All u have to do on this transport is sit there.



I think this is your problem.

Call ALS if neccesary and be on your way.  Delaying care an transportation could be construde a form of abandonment.


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## firecoins (Jul 29, 2010)

I would be transporting.  If they are unstable reroute to a closer ER.


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## JTS (Aug 7, 2010)

cristianb36 said:


> If you think they will crash on you then package them up and depending on ur eta to the closest transport, don't delay tx just to get paramedics there, take em there urself. *My company has tiold me to keep going to destination if its a dnr that dies...I think that's ridiculous.* I've rerouted a dnr to a closest er, and lo and behold we hear from family that indeed their loved one was treated with antibiotics and has had an extended life because we didn't just keep going. Company was initially pissed because the snf cAlled angrily because of our reroute, but gave us a bonus later for making the right call. If they fire you for making the right call move on. Plenty of companies out here. Which company is this btw if u don't mind saying




I personally don't think it is too ridiculous.  It comes down to quality of life.  If I had an active DNR and my life was extended which meant that I had the honor of spending another year at a SNF, I would be pretty angry.


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## Aidey (Aug 7, 2010)

I just re-read that bit that is bolded, and if the patient is dead what on earth does your company expect the ER to do? Our ERs WILL NOT accept a deceased patient who has either been declared dead or who is pulseless with a valid DNR. You can park at the ER, but you are stuck there until the coroner is gets there and takes over. 

As for the example, it was the ER that violated the DNR/Advanced directive, not the ambulance company.


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## zzyzx (Aug 11, 2010)

I think this is a gray area that's probably not covered by your protocols. I don't think anyone would have faulted you for transporting an unstable DNR patient, but I also think you are in your right to refuse to transport an such a patient. You, your dispatcher, or the nursing home should have called for an ALS fire ambulance.

Regardless, I think it's nuts that you are being suspended for your decision. Perhaps you should look for an ambulance company that takes better care of its employees.


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## AtlantaEMT (Aug 13, 2010)

This is pretty interesting and one of the things I have tried to figure out.  I've only seen one DNR and it was during my clinical rotation in the ER.  It was a DNR/DNI.  The patient was in a cardiology room (and the sweetest old lady).  I didn't read through what it said but I noticed it had a bunch of stuff written out below DNR and DNI.  Obviously she was okay with some kind of treatment (had daughters there too).

I just finished EMT-I school but haven't taken my practicals/computer test yet so I don't know squat.  But from what I remember reading in I think Chapter 2 or 3 in my text book (I know you actual EMT/Medics hate that) is that it is better to be sitting in court for trying to do something than sitting in court for doing nothing.  I'd probably try to contact medical control or if possible fax the DNR to a supervisor and possibly the ER to see what they say if time allows.


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## JPINFV (Aug 13, 2010)

AtlantaEMT said:


> I just finished EMT-I school but haven't taken my practicals/computer test yet so I don't know squat.  But from what I remember reading in I think Chapter 2 or 3 in my text book (I know you actual EMT/Medics hate that) is that it is better to be sitting in court for trying to do something than sitting in court for doing nothing.  I'd probably try to contact medical control or if possible fax the DNR to a supervisor and possibly the ER to see what they say if time allows.



It's better to not be in a court room at all, and you'll find yourself in just as much legal trouble if you blatantly disregard a DNR as you would for withholding care from someone who wanted a full court press. This is one of the few issues where you'll find me always say to consult local procedure for honoring DNRs as local procedures can vary wildly from fairly hard to have a 'legitimate' DNR to very very easy. On scene is the absolute worst time to figure out something that could very easily had been learned before the call.


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