# Dnh/dnr



## jemt (Sep 1, 2011)

So i transported back to a nursing home a patient off of Dialysis and I could tell she was going down hill when I was transporting. So we get to the nursing home and the nurse is trying to get her attention but shes not responding at all and barely opening her eyes. I ask the nurse if she wants us to take the pt to the E.R. but the nurse says she is do not hospitalize/DNR.

Now my question is how does a DNH work? Can the patient be in visible/audible distress/pain and they just leave the pt to suffer?


Thanks.


----------



## Lady_EMT (Sep 1, 2011)

I've never heard of "do not hospitalize" before... 

But DNRs are different for each patient. Some may not want any preventative measures, while others will allow some measures, but don't want to be on life support. It depends on this pt's history and DNR details as to what you can do to help this pt. 

Sometimes, people just want to die. They want their time to come, and they want to go peacefully, not with someone breaking every rib and jamming a tube down their throat. It may be difficult to watch, but it's what they want. 

I know an EMT who saw someone code, and because they had a DNR, the EMT had to sit back and watch. He was a firefighter to begin with, and against EMS, and after being forced to sit back and watch someone die, he threw in his towel and decided it wasn't for him.


----------



## WoodyPN (Sep 1, 2011)

I would have simply ensured the patient wasn't feeling any pain, to the best of my provided ability.

As LTC goes, it depends on a lot of things. Where I am, its all or nothing, we either do everything, i.e. full code, or a no code.

Ive had one person who was a full code one minute, his family goes up front to see S.S. and he codes.  As the 911 crew is walking in the door and were working on him, the family and the social worker walks in with the order and tells us to stop. That wasn't fun.


----------



## PFD2171 (Sep 1, 2011)

*Dnh*

It would depend on state laws but as I understand it the DNH/DNR is applicable as long as the patient is a resident of that facility including transfers from and to that facility. It takes family to override that order.


----------



## Aidey (Sep 1, 2011)

It definitely isn't unheard of. In places that use POLST forms there is often a palliative care/comfort care section that specifies not to transport the patient unless their comfort needs can not be met at their current location.


----------



## medicdan (Sep 1, 2011)

DNR/DNI/DNH orders are very common around here. While we have a standardized DNR order in MA (Comfort Care), they are testing a Medical Orders for Life Sustaining Treatment (MOLST-MA)-- which details well the patient or their family's requests. In some situations, they family will allow for treatment and perhaps transport for non-life threatening illnesses, if they increase comfort or decrease pain (if the patient falls and breaks their wrist, they want to have it splinted/castted and get pain relief, and it's unrelated to the end stage cancer)


----------



## ArcticKat (Sep 1, 2011)

We moved from the DNR concept some time ago because it was too limiting.  Instead we have an Advanced Care Directive in which the client is able to list specifically what procedures he or she wants to have performed.  For example, they may choose to be intubated and ventilated, but if their heart stops we are not to conduct CPR.  If they acquire a treatable illness with a good prognosis they can be treated, but if the prognosis is poor, then no treatment.  Stuff like that.


----------



## JPINFV (Sep 1, 2011)

jemt said:


> Can the patient be in visible/audible distress/pain and they just leave the pt to suffer?
> 
> 
> Thanks.



Depending on the situation, yes, and it's not entirely like transporting the patient to the hospital is going to change anything but the room number.


----------



## EMTSTUDENT25 (Sep 2, 2011)

How often do you guys come in contact with a DNR?  We were told in school that there are many forms which are not filled out correctly, making them invalid.  Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?


----------



## JPINFV (Sep 2, 2011)

EMTSTUDENT25 said:


> How often do you guys come in contact with a DNR?  We were told in school that there are many forms which are not filled out correctly, making them invalid.  Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?



Came in contact with them often running IFT, as in probably one every other shift at a minimum, and every shift wasn't too uncommon. 

Yes, many of them aren't filled out with the physicians signature. However, the area I worked in included a provision to withhold or withdraw resuscitation on verbal request from an immediate family member.


----------



## Tigger (Sep 2, 2011)

EMTSTUDENT25 said:


> How often do you guys come in contact with a DNR?  We were told in school that there are many forms which are not filled out correctly, making them invalid.  Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?



Almost every shift I'd bet for an actual DNR. Most patients transferred from sort of assisted living facility had some sort of directive that went with them during transport even of it only told us they were a full code. I'd try to make sure I had their directive before leaving if it wasn't included.


Sent from my out of area communications device.


----------



## Sandog (Sep 2, 2011)

JPINFV said:


> Came in contact with them often running IFT, as in probably one every other shift at a minimum, and every shift wasn't too uncommon.
> 
> Yes, many of them aren't filled out with the physicians signature. However, the area I worked in included a provision to withhold or withdraw resuscitation on verbal request from an immediate family member.



Verbal request from a family member means squat...  Perhaps you spoke in error? If it is as you say, I would love to see the civil code permitting this.


----------



## JPINFV (Sep 2, 2011)

Sandog said:


> Verbal request from a family member means squat...  Perhaps you spoke in error? If it is as you say, I would love to see the civil code permitting this.





> IV. DEFINITIONS:
> F. “Immediate Family” means the spouse, adult child(ren), parent of a patient, adult sibling, or domestic partner (pursuant to Section 297 of the Family Code).
> 
> ...
> ...



http://ochealthinfo.com/docs/medical/ems/P&P/330.51.pdf


Can a family member in your system verbally request that you disregard a DNR? Considering how common it is to find incomplete or missing DNRs, especially with patients on home care, this to me is a very sensible protocol.


----------



## Sandog (Sep 2, 2011)

JPINFV said:


> http://ochealthinfo.com/docs/medical/ems/P&P/330.51.pdf
> 
> 
> Can a family member in your system verbally request that you disregard a DNR? Considering how common it is to find incomplete or missing DNRs, especially with patients on home care, this to me is a very sensible protocol.



Holy Crap, this statement floored me.


> EMS personnel may withhold or withdraw resuscitative measures when presented with a Do Not Resuscitate (DNR) directive or order, as long as it can be reasonably determined that the patient is the subject of the document. EMS personnel may also withhold or withdraw resuscitative measures for patients without DNR documents when immediate family is on scene and they desire to make a unanimous decision to withhold resuscitation.



Glad I do not have a million bucks. This just seems so wrong to me. You convinced me that you are right, but, holy cow, I think it is wrong. Say I wreck my car and a family member wants my house, "Yeah dude, he wants no help man, let him die" Am I interpreting what you posted correctly? Surely there must be a advanced directive in place. Gee, this just seems whacked.

This totally goes against what I was taught in school. Wow, is all I can say.


----------



## JPINFV (Sep 2, 2011)

Sandog said:


> Holy Crap, this statement floored me.
> 
> 
> Glad I do not have a million bucks. This just seems so wrong to me. You convinced me that you are right, but, holy cow, I think it is wrong. Say I wreck my car and a family member wants my house, "Yeah dude, he wants no help man, let him die" Am I interpreting what you posted correctly? Surely there must be a advanced directive in place. Gee, this just seems whacked.
> ...



Oh, noez. The EMT-B classroom isn't the end all, be all of medicine? 

As to the first part of your post, there's always this:

"F. Base contact should be made and the Base Physician consulted and resuscitation should be initiated:

1. If there are any questions regarding validity of the DNR order, or
...
5. If there is disagreement among family members regarding the withdrawal of resuscitative measures, or

6. Anytime EMS personnel have concerns or require assistance."

Pick any of those three if you think that the patent's best wishes aren't being looked after. Resuscitation is not always in the best interest of the patient. 

There's a material difference between the 50 year old in a car accident and the 70 year old with end stage lung cancer who misplaced or never considered getting a formal DNR because they assumed that they, or their family, could actually communicate their wishes with the professionals providing medical care.


----------



## BEorP (Sep 2, 2011)

Sandog said:


> Holy Crap, this statement floored me.
> 
> 
> Glad I do not have a million bucks. This just seems so wrong to me. You convinced me that you are right, but, holy cow, I think it is wrong. Say I wreck my car and a family member wants my house, "Yeah dude, he wants no help man, let him die" Am I interpreting what you posted correctly? Surely there must be a advanced directive in place. Gee, this just seems whacked.
> ...



I would encourage you to think a bit more about this. I highly doubt this is being implemented for 37 year old millionaires with a witnessed VF cardiac arrest.

First of all, a DNR comes into play when someone is in cardiac arrest. It has nothing to do with "letting someone die" since they are already dead physiologically. The chances of a successful resuscitation are quite low as I'm sure you know.

Secondly, the patient who this directive are most likely used for is someone:
- who is old
- who wouldn't have wanted resuscitation but never put their wishes down on paper
- where "successful" resuscitation would win them a stay in ICU and then probably a more drawn out death


We need more EMS systems where providers are not forced to attempt futile resuscitations that the patients never would have wanted.


----------



## LondonMedic (Sep 2, 2011)

A 'Do Not Hospitalise' order on someone who's having dialysis? Really?


----------



## CAOX3 (Sep 2, 2011)

Removed


----------



## MonkeySquasher (Sep 3, 2011)

emt.dan said:


> ..... they are testing a Medical Orders for Life Sustaining Treatment (MOLST-MA)-- which details well the patient or their family's requests.



Oh.  The MOLST was, I believe, created and piloted near me in Rochester NY.  Since then we're finding them more and more in this area.  Prehospitally, I like them, as they lay out exactly what the patient's wishes are, much more precise than a DNR/DNI.




EMTSTUDENT25 said:


> How often do you guys come in contact with a DNR?  We were told in school that there are many forms which are not filled out correctly, making them invalid.  Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?



As others have already covered, there's many factors.  The patient may have a DNR that isn't signed, or is outdated, or is lost, or a photocopy (we're supposed to have the original).  Or maybe the family suddenly tries to recind the DNR because they're thinking with emotion and want everything done.  Or there's an argument within the family about what to do.  I've had all of these situations, and in every one, I just call a doc to get their opinion.  In 2/3, we confirmed the patient where they lay, and in the 3rd we did BLS CPR to the ER (next door) to appease the family.

tl;dr - If you have any questions, like in CA, just phone your Med Control and paint an accurate picture of patient presentation to the doc.  They won't steer you wrong.


----------



## WickedGood (Sep 3, 2011)

EMTSTUDENT25 said:


> How often do you guys come in contact with a DNR?  We were told in school that there are many forms which are not filled out correctly, making them invalid.  Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?



I work for a transport service and about 80% of the people we pick up have DNRs.  They usually hand them to us with the face sheet and the rest of the paperwork and we keep it on the clipboard while we transport.

The other thing we have is a MOST form-- Medical Orders for Scope of Treatment. http://www.ncdhhs.gov/dhsr/EMS/pdf/ncmostform.pdf
I have yet to have seen one of these, however.


----------



## Anjel (Sep 3, 2011)

EMTSTUDENT25 said:


> How often do you guys come in contact with a DNR?  We were told in school that there are many forms which are not filled out correctly, making them invalid.  Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?



We are told by nursing homes they are a DNR all the time. But when transporting that cannot or willnot give us or show us the original.

So if granny decides to circle the drain in my ambulance I have to do every lifesaving measure I can do.


----------



## MrBrown (Sep 3, 2011)

Locally speaking (significant medicolegal differences than the US) we are expected to honour living wills and advanced directives (including verbal directives)

Brown is a fierce advocate of patient rights and patient choice, if the patient has clearly described their wishes be it written, verbal, in mine or Zulu then who are Ambulance Officers to disregard them? That is inappropriate and unethical.


----------



## LondonMedic (Sep 3, 2011)

MrBrown said:


> Locally speaking (significant medicolegal differences than the US) we are expected to honour living wills and advanced directives (including verbal directives)
> 
> Brown is a fierce advocate of patient rights and patient choice, if the patient has clearly described their wishes be it written, verbal, in mine or Zulu then who are Ambulance Officers to disregard them? That is inappropriate and unethical.


Agreed 100%.

I struggle to understand a medical culture where the discussion is about how best to invalidate and ignore DNRs and force treatment on patients.


----------



## MrBrown (Sep 3, 2011)

LondonMedic said:


> I struggle to understand a medical culture where the discussion is about how best to invalidate and ignore DNRs and force treatment on patients.



For you it depends how much you dislike your Consultant 

Speaking of which, Brown may or may not have misidentified you _*as*_ a Consultant ... should keep that handy, print a copy or something, it will come in handy at the pub 



MrBrown said:


> ... LondonMedic ... is a Consultant/...BASICS Doctor, he could be quite useful


----------



## lightsandsirens5 (Sep 3, 2011)

Y'all aren't allowed to honor copies? Really?


----------



## Anjel (Sep 3, 2011)

Nope. 

I was asking our CQI person and she said it has to be original.


----------



## JPINFV (Sep 3, 2011)

LondonMedic said:


> Agreed 100%.
> 
> I struggle to understand a medical culture where the discussion is about how best to invalidate and ignore DNRs and force treatment on patients.



It's the same thing with everything else. An overriding fear of liability is engrained starting with the first class and it's always better to do something than nothing.


----------



## JPINFV (Sep 3, 2011)

BEorP said:


> First of all, a DNR comes into play when someone is in cardiac arrest. It has nothing to do with "letting someone die" since they are already dead physiologically. The chances of a successful resuscitation are quite low as I'm sure you know.



DNRs also come into play in a peri-arrest situation. I would be very hesitant and reluctant to place an advanced airway in a patient circling the drain just because they hadn't finally passed through the drain yet.


----------



## Anjel (Sep 3, 2011)

> A.  EMS providers shall not attempt resuscitation of any individual who meets ALL
> of the following criteria:
> a.  18 years of age or older
> b.  Patient has no vital signs.  This means no pulse or evidence of
> ...



So it doesn't mention anything about originals. So I am not sure. That is out protocol though. It all results in contacting medical control.

But a patients POA and Guardian can verbally request that you not resuscitate IF they can provide the paperwork proving who they are. 

I have been seeing a lot of the bracelets lately. Especially in the hospital.


----------



## emt1000 (Sep 3, 2011)

In response to the initial post. Why if you were transporting a patient to a SNF and did have the DNR in hand and the patient started going downhill enroute, then why did you not divert to a the most accessible receiving facility/ER and instead took the patient back to a SNF? If a patient is deteriorating while being transported and you do not have a do not hospitalize order in hand, then the patient needs to go to an ER and not SNF.

I am a major advocate for patient's rights and DNRs but transporting a patient that is deteriorating back to a SNF in hopes of consulting with the nurse there or finding a DNR sounds like bad patient care to me.


----------



## jjesusfreak01 (Sep 3, 2011)

We don't honor copies of the DNR either. If they won't give me an original (you can make multiple originals), then they don't want me to honor the DNR. Nursing home copies tend to be terrible quality anyways, and I have to be able to read the name on the form. 

Patients who go downhill during transport (IFT) get a quick diversion towards the hospital and an ALS intercept if its quicker.


----------



## JPINFV (Sep 3, 2011)

If a patient has a DNR, especially if the patient is on hospice, what is the ED going to do for the patient who is going down hill?


----------



## JPINFV (Sep 3, 2011)

jjesusfreak01 said:


> We don't honor copies of the DNR either. If they won't give me an original (you can make multiple originals), then they don't want me to honor the DNR. Nursing home copies tend to be terrible quality anyways, and I have to be able to read the name on the form.



Then, ideally, you should make a duplicate copy of your PCR for the ED. After all, copies, be them carbon copies or photocopies, are often poor quality. Why should the ED accept care of your patient if you aren't willing to make them an original of your PCR? Oh, and make sure to include enough originals for the floor unit and what ever facility the patient is discharged to.

A DNR is a long term document that is needed in multiple charts. Why should a SNF give you the original when they need the original for their chart? The patient's wishes shouldn't depend on a game of "who has first" and ensure that a single document is properly tracked and handed back and forth.


----------



## Anjel (Sep 3, 2011)

JPINFV said:


> Then, ideally, you should make a duplicate copy of your PCR for the ED. After all, copies, be them carbon copies or photocopies, are often poor quality. Why should the ED accept care of your patient if you aren't willing to make them an original of your PCR? Oh, and make sure to include enough originals for the floor unit and what ever facility the patient is discharged to.
> 
> A DNR is a long term document that is needed in multiple charts. Why should a SNF give you the original when they need the original for their chart? The patient's wishes shouldn't depend on a game of "who has first" and ensure that a single document is properly tracked and handed back and forth.



Its not a personal choice not to honor them. Its policy. 

And out pcrs are electronic and.faxed to the ED after we leave.


----------



## Anjel (Sep 3, 2011)

Also if I can at least see the original and take a copy thats fine. I just need to see it


----------



## usalsfyre (Sep 3, 2011)

Apparently there's a banner business out there manufacturing counterfeit copies of DNR orders .

Of course, the legislature in my state just set patient choice through advanced directives back 10 years...


----------



## jjesusfreak01 (Sep 3, 2011)

JPINFV said:


> Then, ideally, you should make a duplicate copy of your PCR for the ED. After all, copies, be them carbon copies or photocopies, are often poor quality. Why should the ED accept care of your patient if you aren't willing to make them an original of your PCR? Oh, and make sure to include enough originals for the floor unit and what ever facility the patient is discharged to.
> 
> A DNR is a long term document that is needed in multiple charts. Why should a SNF give you the original when they need the original for their chart? The patient's wishes shouldn't depend on a game of "who has first" and ensure that a single document is properly tracked and handed back and forth.



All of our PCRs are digital and (when im working EMS) are immediately available to the hospital once completed. In North Carolina, at least one original DNR is supposed to be kept with the patient. Wherever i'm transporting a patient to needs the DNR just as much as I do.


----------



## BEorP (Sep 3, 2011)

JPINFV said:


> DNRs also come into play in a peri-arrest situation. I would be very hesitant and reluctant to place an advanced airway in a patient circling the drain just because they hadn't finally passed through the drain yet.



Fair point. What I was more meaning is that a DNR doesn't mean that if someone crashes their car and you get there and (somehow) find out that they have a DNR and a broken leg that you just walk away.


----------



## JPINFV (Sep 3, 2011)

jjesusfreak01 said:


> All of our PCRs are digital and (when im working EMS) are immediately available to the hospital once completed. In North Carolina, at least one original DNR is supposed to be kept with the patient. Wherever i'm transporting a patient to needs the DNR just as much as I do.



The problem is the insanity of the issues surrounding DNRs with EMS. No one else puts so many restrictions and a physician when faced with a valid DNR order, be it a written order in a chart, or the state approved plaid colored form, is going to honor the DNR. I don't understand EMS's obsession with having to be different from everyone else.


----------



## JPINFV (Sep 3, 2011)

BEorP said:


> Fair point. What I was more meaning is that a DNR doesn't mean that if someone crashes their car and you get there and (somehow) find out that they have a DNR and a broken leg that you just walk away.



True, however I don't think anything that a DNR order directly restricts would be pertinent to a broken leg anyways. Now if the car accident victim needs to be intubated to protect his/her airway you've ran into a significant problem.


----------



## jemt (Sep 4, 2011)

emt1000 said:


> In response to the initial post. Why if you were transporting a patient to a SNF and did have the DNR in hand and the patient started going downhill enroute, then why did you not divert to a the most accessible receiving facility/ER and instead took the patient back to a SNF? If a patient is deteriorating while being transported and you do not have a do not hospitalize order in hand, then the patient needs to go to an ER and not SNF.
> 
> I am a major advocate for patient's rights and DNRs but transporting a patient that is deteriorating back to a SNF in hopes of consulting with the nurse there or finding a DNR sounds like bad patient care to me.




This patient is in her late 90's and not completly with it to begin with. If you try to say anything to her all you get is a hi and thats it. Also many PT's I transport are normally weak after Diaylsis and her vital signs were all fine. On this day she wasn't responding verbally but reconized I was talking to her.

I wasn't insinuating she was crashing rapidly but that she wasn't herself this particular day. I asked to nurse if she wanted us to transport to the E.R. because she seemed overly concerned.


----------



## Bullets (Sep 5, 2011)

JPINFV said:


> Then, ideally, you should make a duplicate copy of your PCR for the ED. After all, copies, be them carbon copies or photocopies, are often poor quality. Why should the ED accept care of your patient if you aren't willing to make them an original of your PCR? Oh, and make sure to include enough originals for the floor unit and what ever facility the patient is discharged to.
> 
> A DNR is a long term document that is needed in multiple charts. Why should a SNF give you the original when they need the original for their chart? The patient's wishes shouldn't depend on a game of "who has first" and ensure that a single document is properly tracked and handed back and forth.



thats why we use ePCRs, once i upload, they go into the hospitals server and are available to anyone in the building

I just need to be able to read the patients name, and cant be a xerox of a xerox of a black streaked xerox

And the whole family request thing, that just seems hinky


----------



## btkspot89 (Oct 26, 2011)

I know im chiming in a little late here and I apologize, but I have came across these DNH's on numerous occasions. Anytime I run in to them I always have some sort of problem. Now in EMT class they teach you about the DNR, but when I ran into a DNH order it caught me off guard. The first time I was called to one of our contracted facilities for a patient who was refusing to eat. The staff at that facility tried to force feed the patient and almost made him choke, so they called us. The patient was alert and oriented and refused to go to the hospital. Also when I checked the paperwork I came across this DNH order. When I questioned the staff at that facility as to why they were ignoring a signed doctors order to not send the patient to the hospital. They tried to act like they had never seen the paperwork before. So after about 10 minutes of the staff talking they decided to call the doctor, who backed up his signed order. The family got there and while they tried to talk to him as well the patient still said "no" So with a patient refusal and a seeing a signed DNH we left.

Now this brings up my question which im pretty sure I know the answer too. Can the staff at an extended care facility override the patients orders?


----------



## JPINFV (Oct 26, 2011)

btkspot89 said:


> Can the staff at an extended care facility override the patients orders?



Provided the patient has capacity and there isn't any sort of special legal order (like a conservatorship in California. Power of attorney only goes into effect if the patient lacks capacity/is incapacitated), no.


----------

