# DNR Order



## Alas (Aug 14, 2010)

Scenario: I'm transporting a patient who has a valid dnr and the pt's wife (or significant other) is riding along in the back. The patient goes into cardiac arrest, and the wife tells me she wants him to be resuscitated and becomes frantic. What do?


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## JPINFV (Aug 14, 2010)

Since you list your location as San Fransisco, 



> *VI. SPECIAL CONSIDERATIONS
> *d). In the case the patient is unconscious and family members present are requesting resuscitative measures, initiate BLS treatment and contact the base physician.
> ...
> *VII.  BASE HOSPITAL CONTACT*
> ...



http://www.sfdem.org/Modules/ShowDocument.aspx?documentid=224


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## Cawolf86 (Aug 14, 2010)

The correct answer would be to start BLS procedures (including defib) and contact your base hospital for further direction. This is laid out in EMS Policy 814.


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## Amycus (Aug 14, 2010)

I know you're in Cali, but for what it's worth in MA, if there is a valid DNR but the healthcare proxy or whomever (like the wife or such) requests CPR to start, the DNR gets destroyed and is immediately rendered invalid.


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## JPINFV (Aug 14, 2010)

Cawolf86 said:


> The correct answer would be to start BLS procedures (including defib) and contact your base hospital for further direction. This is laid out in EMS Policy 814.



Really? 814 eh? There is no policy 814 in Orange County. Orange County LEMSA's DNR policy can be found under 330.51. The OP is no where close to LA, hence why I quoted and provided the link for San Fransisco's LEMSA's DNR policy. The San Fransisco DNR policy is policy number 4051 and listed above.


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## firecoins (Aug 14, 2010)

Reguardless of what state your in, you start CPR.  THe DNR has become invalid.


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## Cawolf86 (Aug 14, 2010)

JPINFV said:


> Really? 814 eh? There is no policy 814 in Orange County. Orange County LEMSA's DNR policy can be found under 330.51. The OP is no where close to LA, hence why I quoted and provided the link for San Fransisco's LEMSA's DNR policy. The San Fransisco DNR policy is policy number 4051 and listed above.




JPINFV - my apologies. I blindly referenced LA County policy as his own. After studying policies all day I am going to pardon myself here. Hope you will do the same. I enjoy reading your posts. 

If my "correct answer" offended at all apologies as well. It was meant to read as "on a test the answer would be". 

Sorry again.


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## Fox800 (Aug 14, 2010)

In Texas, it depends on who enacted the DNR. If the pt. enacted the DNR, it can only be revoked by the pt. or a physician. The family cannot revoke a DNR enacted by the pt. Unfortunately this is an area where many providers are lacking education (regarding their state regulations on DNRs).


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## JPINFV (Aug 14, 2010)

The problem is you worded it as if LA LEMA's policy was statewide policy, which isn't the case. This is a huge issue when you consider, for example, that San Fransisco's policy doesn't allow a verbal request to withhold resuscitation from immediate family members, whereas OC LEMSA and LA LEMSA does.


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## Shishkabob (Aug 14, 2010)

Fox800 said:


> In Texas, it depends on who enacted the DNR. If the pt. enacted the DNR, it can only be revoked by the pt. or a physician. The family cannot revoke a DNR enacted by the pt. Unfortunately this is an area where many providers are lacking education (regarding their state regulations on DNRs).



Mmm, no. 

Medical poa, family, and the patient can revoke at anytime. 

It's up to your med control if they want you to work it or not.


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## Akulahawk (Aug 14, 2010)

Santa Clara County's Policy for the OP's situation is part of Policy 604:



> In the event that a patient presents with any DNR form with
> which the Prehospital personnel is not familiar, continue CPR
> and immediately contact the Base Hospital for direction.  *Every
> effort shall be made to honor the wishes of the patient even if
> ...


The "supportive care" does not include resuscitation measures such as compressions...

Sacramento County Policy 2085.11 simply states: 


> If there are any questions, provide for patient comfort including BLS CPR, if
> indicated, and utilize direct medical oversight.


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## HelpmeHelpyou (Aug 14, 2010)

This is almost on par to what questions I was going to ask in class when this subject was brought up in CH.2 of my textbook. 

This is when policy seems to out weigh logic in some states, I am glad this was brought up.


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## Fox800 (Aug 14, 2010)

Linuss said:


> Mmm, no.
> 
> Medical poa, family, and the patient can revoke at anytime.
> 
> It's up to your med control if they want you to work it or not.



Can you provide TDSHS regulations or state law to verify this? The medicolegal class I took and my medical director both teach that only the person who enacted the DNR or a physician can revoke it. I'm sure we'd be facing a lot of heat with this policy if it wasn't permissible under state law.


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## Shishkabob (Aug 15, 2010)

I guess it comes down more to semantics, because like I said, the final determination of if you work the code is up to your MC, but it's still the family "revoking" it.


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## AlphaButch (Aug 15, 2010)

In Texas, the wife would be a qualified family member and is able to revoke the DNR. (It's on the DNR form)

Publications No. EF01-11421 TEXAS DEPARTMENT OF STATE HEALTH SERVICES STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER 25 TAC §157.25 (h)(2)

"REVOCATION:
The Out-of-Hospital Do-Not-Resuscitate Order may be revoked at ANY time by the patient OR the patient’s Legal Guardian/Agent/Managing Conservator/
Qualified Relative, Parent (if a minor), or physician who executed the order. The revocation may involve the communication of wishes to
responding health care professionals, destruction of the form, or removal of all or any Do-Not-Resuscitate identification devices the patient may possess."

"Qualified Relatives: Those persons authorized to execute or issue an out-of-hospital DNR order on behalf of a person who is comatose, incompetent,
or otherwise mentally or physically incapable of communication under Section 166.088 H&SC Section 166.088 refers to 166.039; “One person, if
available, from one of the following categories, in the following priority...: (1) The patient’s spouse; (2) the patient’s reasonably available adult children;
(3) the patient’s parents; or (4) the patient’s nearest living relative.”


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## Akulahawk (Aug 15, 2010)

It just goes to show "you" that knowledge of DNR matters, matters. Make sure you know who may legally revoke a DNR/No Code/Advanced Directive in your state. It may just save your bacon someday!


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## gw812 (Aug 15, 2010)

AlphaButch said:


> In Texas, the wife would be a qualified family member and is able to revoke the DNR. (It's on the DNR form)
> 
> Publications No. EF01-11421 TEXAS DEPARTMENT OF STATE HEALTH SERVICES STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER 25 TAC §157.25 (h)(2)
> 
> ...



Thanks for posting the regs! It's appreciated. Got a question - does this person have to be listed on the DNR, kinda like a power-of-attorney, or just any of those people present themselves (following the order of priority)? I'd think that besides the spouse there'd be a problem with proving you're one of those people.


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## Shishkabob (Aug 15, 2010)

They don't need to be listed on the DNR.

However, if you question it, do CPR while you call med control.


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## AlphaButch (Aug 15, 2010)

As Linuss stated. They don't have to be listed. 

If in doubt, do cpr and contact med control. It's easier to cease resuscitation,  than it is to try to resuscitate someone after they've been down for the time it takes for med control. It's also easier to defend should you end up in court. 

On the other side - If there is any reason to suspect that a DNR is not valid, resuscitation efforts should be started and med control contacted. (as per TSDHS regs as well).

Note* I don't know any other state regs other than TX.


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## Akulahawk (Aug 15, 2010)

AlphaButch said:


> As Linuss stated. They don't have to be listed.
> 
> If in doubt, do cpr and contact med control. It's easier to cease resuscitation,  than it is to try to resuscitate someone after they've been down for the time it takes for med control. It's also easier to defend should you end up in court.
> 
> ...


It is indeed far easier to cease efforts after confirming a DNR order is valid than it is to raise the dead after a prolonged down-time. After all, at some point, you'd be more successful trying to resuscitate a rock...

Know what is considered a valid DNR, who can order you to stop, and who can countermand a valid DNR. Always have the paperwork OR someone who can legally request that you start, or stop, efforts. I've had to work patients that I (and everyone else) "knew" were DNR, but nobody could find their paperwork and nobody present had legal authority to order that I stop...


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## AtlantaEMT (Aug 15, 2010)

If a family member can act as a medical proxy, do we need full confirmation that she/he is their husband/wife?  The reason I am wondering this is becuase I had a guy in a hemorragic stroke and we had this woman who I thought was this guy's wife at the time.  Now if this guy went into full arrest and we had a DNR I wouldn't have put it past this woman to claim that she is his wife and want him to be resuscitated.  She was crazy enough to claim an EMT who was trapped on the backside of the elevator by the stretcher assaulted/pushed her.

Would we need to match driver licenses?  But then again my GF and I live together and we have the same address and two non-married partners could have the same last name too.  I know it's usually easy to figure out if someone is married but I'd hate to tear up a DNR and find out that the person had no control over this person.


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## Alas (Aug 30, 2010)

Very informative replies. I've had a few close DNR situations but they never came, but they made me ask questions. I do live in San Francisco. Followup scenario: who has the right to call off a dnr while in the ambulance? Spouse of PT? Brother? Distant Relative?


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## JPINFV (Aug 30, 2010)

If only there was a government website that provides answers to questions of protocol and procedure for providers to look at...



> d). In the case the patient is unconscious and family members present are requesting resuscitative measures, initiate BLS treatment and contact the base physician.



http://www.sfdem.org/Modules/ShowDocument.aspx?documentid=224

There's no mention to this being limited to just the scene and not transport. 

Why do I enable people to not do their own research?


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## Medic50321 (Aug 30, 2010)

firecoins said:


> Reguardless of what state your in, you start CPR.  THe DNR has become invalid.



Agreed, same in Iowa


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## MrBrown (Aug 30, 2010)

Brown would politely decline to get involved and go back to surfing Facebook on his phone 

/sarcasm

... well at least about the surfing Facebook on his phone part


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## Saytuck99 (Aug 30, 2010)

*New York*

In New York..


A living will or health care proxy is NOT valid in the prehospital setting.

Under what circumstances may an EMS provider disregard an Out of Hospital DNR order?

    * Any case where there is reasonable evidence to suggest that the DNR order has been revoked or cancelled.
    * If the patient is conscious and states that they wish resuscitative measures, the DNR Form should be ignored.
    * If the patient is unable to state his or her desire and a family member is present and requests resuscitative measures for the patient and a confrontational situation is likely to result, if the request is denied.
    * A physician directs that the order be disregarded.

This is part of the DOH regs and I recently taught a seminar on this topic..technically if a DNR Order is valid... a family member is unable to revoke it...even if they are the Health Care Proxy..POA or whatever..

Thats does not mean that if a guardian or Proxy authorized issuance of the DNR they cannot revoke it...it means that if the patient has a valid DNR they authorized technically only the patient and/or medical control/physician can invalidate it.... the pleading of a family member, however, might serve as evidence the DNR is invalid...wink wink..

This is a complicated area...and my response by no means covers all aspects...and no one should rely on this post without first checking with their state regs and dept policies.....

There...disclaimer over...


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## jjesusfreak01 (Aug 31, 2010)

If you are a family member and you don't want the DNR followed, don't show EMS the DNR. Its really that simple. If they don't know it exists, then they work it no matter what. All this talk about a family member revoking it means that they really didn't prepare well for this to happen (not that you can).


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## jms81 (Sep 25, 2010)

Know your local protocol, follow it, and always follow up with detailed documentation.


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## Trip (Sep 26, 2010)

JPINFV said:


> If only there was a government website that provides answers to questions of protocol and procedure for providers to look at...
> 
> 
> 
> ...



I guess all I can say is take it as you will. Luckily there is a good faith clause to protect honoring a DNR or MOLST form.

New York is similar and a HCP cannot revoke, only a family member and, even then, it's only if a confrontation is imminent from the family member. However, a new act went into effect in June of 2010 that makes the whole thing somewhat confusing, but does state 





> The law does not expand the ability of EMS personnel to honor advance directives such as a Health Care Proxy or Living Will.



http://www.nyhealth.gov/nysdoh/ems/pdf/99-10.pdf

http://www.nyhealth.gov/nysdoh/ems/pdf/10-05.pdf


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## DezertRanger-EMT (Oct 12, 2010)

here in Kern county the DNR order hast to be present, other wise you do what you can to keep them alive, if the family gets mad they cant do anything without the DNR order with them, you are just doing your job and following protocol.


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## Shishkabob (Oct 12, 2010)

DezertRanger-EMT said:


> here in Kern county the DNR order hast to be present, other wise you do what you can to keep them alive, if the family gets mad they cant do anything without the DNR order with them, you are just doing your job and following protocol.



Erm... if you start working the code and the family says they don't want you to, regardless of whether or not they have a valid DNR you should call med control and punt the decision off to them.  

Chances are the doc will tell you to call it.


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## DezertRanger-EMT (Oct 12, 2010)

Linuss said:


> Erm... if you start working the code and the family says they don't want you to, regardless of whether or not they have a valid DNR you should call med control and punt the decision off to them.
> 
> Chances are the doc will tell you to call it.


 
yeah it is protocol to contact medical direction you are rite.


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## lampnyter (Oct 12, 2010)

we were taught if they had a valid DNR no matter what the family says we follow the DNR


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## EMS/LEO505 (Oct 12, 2010)

We haven't covered legal aspects fully yet in class, but I asked about DNR orders and in NM the DNR must be in hand for it to apply in that situation.


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## JPINFV (Oct 12, 2010)

DezertRanger-EMT said:


> here in Kern county the DNR order hast to be present, other wise you do what you can to keep them alive, if the family gets mad they cant do anything without the DNR order with them, you are just doing your job and following protocol.




Note entirely true per Kern County LEMSA's website. 

Besides a DNR, the following are acceptable

Living wills

Power of attorney documents that specifically include DNR style language (the policy says it can be in lay person language with an example being "no breathing tube")

The durable power of attorney: health care can give a verbally decline.

Medic alert bracelets. 


http://www.co.kern.ca.us/ems/DNRGuidelines1992.pdf


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## JPINFV (Oct 12, 2010)

lampnyter said:


> we were taught if they had a valid DNR no matter what the family says we follow the DNR




In general, every DNR policy I've seen has stated to begin resuscitation, and if need be, punt to medical control if the family member requests resuscitation. For all you know, the patient requested resuscitation prior to collapsing.


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## Shishkabob (Oct 12, 2010)

lampnyter said:


> we were taught if they had a valid DNR no matter what the family says we follow the DNR



I don't know where you live, therefor I don't know your local laws, but if a direct family member states work them, regardless of a DNR, we work them whilst contacting med control.  

If one family member says work them, and 20 say don't work, you still work until you get a doc on the line.


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## JPINFV (Oct 12, 2010)

EMS/LEO505 said:


> We haven't covered legal aspects fully yet in class, but I asked about DNR orders and in NM the DNR must be in hand for it to apply in that situation.



http://www.nmems.org/Treatment guidlines/Microsoft Word - Treatment Guidelines 2008.pdf

Page 48.

When ever possible, go to the source document. The New Mexico DNR protocol trumps anything your teacher or future bosses say.


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## lampnyter (Oct 12, 2010)

Revocation (19a-580d-7)

A DNR order may be revoked by the patient or authorized representative by removing the bracelet from the patient, or telling an individual licensed healthcare provider or certified emergency medical technician. Such healthcare provider or emergency medical technician must enter the statement in the patient's permanent medical record and notify the attending physician and the physician who issued the DNR order.

http://www.cga.ct.gov/2005/rpt/2005-R-0455.htm


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## Charmeck (Oct 15, 2010)

How about a MOST form?


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## himynameismj (Oct 16, 2010)

Alas said:


> Scenario: I'm transporting a patient who has a valid dnr and the pt's wife (or significant other) is riding along in the back. The patient goes into cardiac arrest, and the wife tells me she wants him to be resuscitated and becomes frantic. What do?



yeah, it sucks the way legislation works. if i want dead, i want dead!


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## Medic41Mike (Oct 18, 2010)

San Joaquin County EMS policy 5105

"If a patient with a valid DNR order is unconscious and family members request resuscitative measures, prehospital emergency medical care personnel are to honor the DNR order. If necessary to preserve scene safety, prehospital emergency medical care personnel may initiate basic life support resuscitation while contacting the Base Hospital for assistance and direction."

I strongly believe in honoring the patients last wish by following out the DNR , granted that it is present, regardless of what the family onscene wishes are. If they become verbally combative, announcing over the radio that,  "Law Enforcement is needed to our scene" generally calms them down.


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## JPINFV (Oct 18, 2010)

...and here's the link for that. On another note, San Joaquin has the best laid out government EMS website I've ever seen. 

http://www.sjgov.org/ems/PDF/Policies/5105_DNR.pdf


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