# Dnr



## mikie (Jun 13, 2008)

So you're dispatched to a parking lot where you find an elderly woman laying on the ground with bystandards doing CPR

You move her into the ambulance, apenic & pulseless, cut her shirt off and see DNR tattooed across her chest.  No proof of DNR documents (in purse/wallet), no family around.

Where do you go from there?

(this may very protocol to protocol so just let us know what either your protocol is or what you would personally do)

thanks!


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## mdtaylor (Jun 13, 2008)

Was it signed and notarized? Is a tatoo a legal document in your state?

Here, the protocol would be to resuscitate.


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## JPINFV (Jun 13, 2008)

Work the code pending medical control contact (paramedic arrival in my case). The problem with tatoos is that they lack the ability to revoke them. Unlike, say, a medic alert bracelet (a valid DNR 'document' in California), if a patient decides not to have a DNR anymore, it's slightly harder to remove/nullify the tatoo.


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## VentMedic (Jun 13, 2008)

Can you be absolutely sure DNR are not the initials of her loved one?

A DNR document contains binding legal language that must accompany the signatures.

When just the letters "DNR"  is referenced in a Physician's Order in a hospital, there is usually accompanying paperwork elsewhere in the chart or a set protocol that is acknowledged.


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## BossyCow (Jun 13, 2008)

Hmm so if I want a DNR tattoo it should read.. DNR... Paperwork in wallet?


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## mdkemt (Jun 13, 2008)

BossyCow said:


> Hmm so if I want a DNR tattoo it should read.. DNR... Paperwork in wallet?



OMG!!  That is awsome...I would almost pay to see that!


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## Ridryder911 (Jun 13, 2008)

If you want a DNR to be valid, it better meet the State & local requirements. Each state varies, my States is only good for one year and the patient has to have a diagnosed terminal disease, and signed by a licensed medical physician as well as notarized. 

First thing I check is to see how long it took to me to respond, and if how long the patient has been down. > 15 minutes without any intervention, their dead. Call the M.E. and get the next call... 


R/r 911


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## CFRBryan347768 (Jun 13, 2008)

JPINFV said:


> Work the code pending medical control contact (paramedic arrival in my case). The problem with tatoos is that they lack the ability to revoke them. Unlike, say, a medic alert bracelet (a valid DNR 'document' in California), if a patient decides not to have a DNR anymore, it's slightly harder to remove/nullify the tatoo.



What if at her midlife crisis she got it as a joke? heh. Id try and have legit papers presented, while working her up.


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## CFRBryan347768 (Jun 13, 2008)

VentMedic said:


> Can you be absolutely sure DNR are not the initials of her loved one?



Or the head of the Department of Natural Resources? Or just a dedicated employee to them heh.


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## JPINFV (Jun 13, 2008)

CFRBryan347768 said:


> What if at her midlife crisis she got it as a joke? heh. Id try and have legit papers presented, while working her up.



If you're wearing a MedicAlert DNR bracelet as a joke and it gets used, then you deserve what you get because the only one laughing will be Darwin. Besides, MedicAlert requires proper documentation before they even process an order for a DNR bracelet. California actually contracts with MedicAlert to provide such a service, so technically, the bracelet ARE legit documentation. 

http://www.medicalert.org/Main/AdvanceDirectives.aspx 

http://www.emsa.ca.gov/pubs/emsa-111.asp


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## CFRBryan347768 (Jun 13, 2008)

JPINFV said:


> If you're wearing a MedicAlert DNR bracelet as a joke and it gets used, then you deserve what you get because the only one laughing will be Darwin. Besides, MedicAlert requires proper documentation before they even process an order for a DNR bracelet. California actually contracts with MedicAlert to provide such a service, so technically, the bracelet ARE legit documentation.
> 
> http://www.medicalert.org/Main/AdvanceDirectives.aspx
> 
> http://www.emsa.ca.gov/pubs/emsa-111.asp



I wasn't talking about the bracelet I was talking about the tattoo.


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## Dominion (Jun 13, 2008)

Here we work them.  The only way we won't work a DNR is when we have seen physically the original DNR with either two valid signatures or nortarized.  We can see the original and carry a copy in the transport in case of arrest enroute.  But we have to see the original and it all is required to be documented.  You can't provide the original, or the original doesn't have two signatures or isn't notarized, we're required to work it.


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## JPINFV (Jun 13, 2008)

CFRBryan347768 said:


> I wasn't talking about the bracelet I was talking about the tattoo.



So then you agreed with my first post. I was kinda of confused because it looked like you were replying about the MedicAlert medallions.


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## traumateam1 (Jun 13, 2008)

No paperwork, no DNR.. unless we find something on her (wallet, purse or something) that is signed and notarized then CPR will continue.. just like if you walk into someone home and there is someone laying on the ground that needs CPR, but the daughter, or son tells you there is a DNR but cannot produce it for you to see then you continue with CPR..
Well thats my two sense


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## JPINFV (Jun 13, 2008)

traumateam1 said:


> just like if you walk into someone home and there is someone laying on the ground that needs CPR, but the daughter, or son tells you there is a DNR but cannot produce it for you to see then you continue with CPR..
> Well thats my two sense


Obligatory comment that this is pursuant to local protocol/procedures for DNRs (hint, that situation is a DNR where I worked).


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## CFRBryan347768 (Jun 13, 2008)

JPINFV said:


> So then you agreed with my first post. I was kinda of confused because it looked like you were replying about the MedicAlert medallions.



Yes I 110% agree with your first post.


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## KEVD18 (Jun 13, 2008)

this one isnt even a challenge.

no paper, heroic measures.


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## mikeylikesit (Jun 14, 2008)

but wait....what if they had the whole document and notarization stamped on them as well?....dumbest tattoo ever. i do abide...sometimes by those stickers on peoples helmets that say "don't remove helmet unless at the ER" or something to that effect, the only time i do it anyways is when you know all the other things that can happen and will happen at an accident take place. e.g.repiratory distress. sorry buddy I'm not taking your sticker seriously enough to not render necessary care.


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## KEVD18 (Jun 14, 2008)

mikeylikesit said:


> but wait....what if they had the whole document and notarization stamped on them as well?....



well then they would have an active dnr and the foolish tatoo would be irrelevant


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## mdtaylor (Jun 14, 2008)

It seems to me the tatoo is merely a reminder to the medics to ASK if anyone present has a valid DNR that they would like to produce prior to resuscitation efforts beginning.


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## mikeylikesit (Jun 15, 2008)

i think that some people got DNR tattoo's after the song came out and they thought it would be like DNR "don't try and save me...i'm already dead" just examining the possibilities here.


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## AJemt (Jun 15, 2008)

no OOH-DNR - work it.  unless you can find paperwork in which case i'm still not going to waste any time looking for paperwork at the expense of providing pt care - if its just me (qrs) i'll be working till someone shows up to help and then either they or i can look quickly to see if there's anything on her - otherwise we keep working.  if we actually do find anything i'm calling med command to stop IF all paperwork/whatever is in order, then of course document the bejeebers out of the call.....


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## BossyCow (Jun 15, 2008)

I think the whole tattoo idea started with a nurse in Oregon. She had the red circle with a line through it over the letters CPR tattooed on her chest. But that was some years back. We have been through the evolutions of having to document that we examined the no-code bracelet and determined that it did not appear that the pt had attempted to remove it, thus showing they had changed their minds about their status. 

Currently the POLST used in my state covers all the options. It has to be continually updated and covers not just do you start CPR but what methods and interventions you do and don't want. I can't count the number of times I've been on calls where the family swears they have a DNR but just can't find it right now, and it turns out  never to have been signed. I personally don't want to put my house and future financial security on the line for a disagreement between family members over who loved mom more. 

I've also been to a pt where I know there was a signed POLST because I'd seen it, but her husband denied that it existed. He just wasn't ready to let go yet. So, in the field, we brought his wife in with CPR in progress. Her POLST was never made a part of her hospital record so she spent about a week in CCU before she died. 

Birth and death are highly personal processes. It's impossible to say how a family should deal with the end of life. We all have our opinions on the matter, but those are based on our emotional, spiritual and financial preferences. The blame stage of the grief process is where the family looks for someone to blame for Grandma's being gone from their life. I personally will make sure that my butt is legally covered when they turn the attorney's binoculars on me.


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## emtd29 (Jul 3, 2008)

No PAPER DNR = I'm working it


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## newbie (Jul 8, 2008)

Is the Pt salvageable?  And do you have a DOA protocol that this Pt. fits?  Failing that Med control Dr.'s make more $ than me and I figure that is because they get to make decisions like that.  I figure a Pt. w/ a DNR tattoo doesn't want to be worked.  Now I just gotta make sure don't get jammed up for not working them.
J


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## mikie (Jul 8, 2008)

interesting a great solutions...

Now just to ask a question

A day later you find out that the patient was indeed DNR (a family member gave proof to the authorities)...could they sue or take any other action?


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## JPINFV (Jul 8, 2008)

mikie333 said:


> Now just to ask a question
> 
> A day later you find out that the patient was indeed DNR (a family member gave proof to the authorities)...could they sue or take any other action?



I don't see how they could. Assuming that the local protocol *requires* a paper DNR to be present and properly filled out (most, *but not all,* do), then I don't see any way to hold a prehospital medical team 'accountable' for attempting to revive a patient. There are zero proper medical orders against treatment as there would be if a proper DNR was present.


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## JPINFV (Jul 8, 2008)

newbie said:


> Is the Pt salvageable?  And do you have a DOA protocol that this Pt. fits?
> J



Salvageable has nothing to do with a DNR. A patient that fits into a DOA/don't start/end resuscitation protocol should fall under that protocol. A patient with a full DNR should fall under a DNR. A patient with obvious signs of death shouldn't be worked regardless of DNR status. A DNR patient should not have resuscitation (resuscitation!=treatment) attempted regardless of if they are salvageable.


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## MRE (Jul 9, 2008)

The only thing a tattoo like that will make me do is look twice to try and find the DNR paperwork.  No paperwork, then they are getting worked.


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## karaya (Jul 9, 2008)

29 posts so far about a DNR tattooed on someone's chest?  Incredible.  I wish there was this much concern about how medics can improve their intubation success rate.


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## Jon (Jul 9, 2008)

With that, it is now 30...I'll make it 31
In PA, they have to have an official state-approved bracelet. A DNR tattoo would make me take another look for the braclet, and perhaps check their wallet/purse for paperwork... but no bracelet, then my medic would call command and discuss the situation. Until command calls the code, we work it.


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## BossyCow (Jul 9, 2008)

karaya said:


> 29 posts so far about a DNR tattooed on someone's chest?  Incredible.  I wish there was this much concern about how medics can improve their intubation success rate.



Isn't part of intubation knowing whether or not to intubate (i.e. DNR protocols?)

And regarding the question by another poster about 'can they sue'. Anyone can always sue, even over silly things, but will they end up with anything other than bills from their lawyer is the real question. If you did CPR on someone who later turned out to have a DNR that wasn't presented to you, they most likely wouldn't be able to show you did something wrong which is part of the process for determining fault, resulting in damage, paid for by fat settlement


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## karaya (Jul 9, 2008)

BossyCow said:


> Isn't part of intubation knowing whether or not to intubate (i.e. DNR protocols?)


 
Wasn't the same frame of comparison I was talking about.  The answer to the question about what to do if one sees DNR tattooed on someone's chest is rather simplistic.


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## Robby1974 (Jul 24, 2008)

In Nevada the documens for DNR must be reapplied for once a year and require a dr's signature. In our course our instructor indicated that DNR's are very rare in Las Vegas because there are very few physicians that are willing to sign off on them. In the case of a tattoo we would need to have the appropriate form signed off by the county, physician, and not expired. In the 8 years that our instructor ran paramedic calls here in the valley he never saw even 1 "valid" DNR order. 

So no go on the DNR tattoo....resuscitate.


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## KEVD18 (Jul 24, 2008)

yet another topic that cant be allowed to rest in peace. somebody just has to keep digging it up.

jon said it much better than i did. a dnr tattoo would make me take another look for the paperwork, but at the end of the day, no paperwork=full resuscitation measures until relieved by a higher level of licensure. be it the medic or the doc. no questions, comments or concerns.


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## SCFD8REZ (Jul 30, 2008)

This is so clear cut, if she doesnt have a signed and notarized DNR order present then as a care provider it is negligence if you dont try to revive based on her tatoo, this is just silly. for all you know the tatoo could stand for Dan Noel Ramos who was her husband or something like that.


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## YouthCorps1 (Nov 13, 2008)

call medical control ... see what they say...and recesitate


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## KEVD18 (Nov 13, 2008)

wow.....you brought up a deceased thread to add that????????????????????


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