CPR in progress, with a DNR

[JPINFV]

you're also not considering that some services required olmc for standing orders(an abomination in and of it self, but the fact remains...).

Don't go there. :wacko::sad:

 

[BossyCow]

I had a call where the pt was a frequent flier and we had watched her slow decline due to CHF and Bladder Cancer over a number of years and dozens of calls. She was the grandmother of an EMT with a local private ambulance service and we all knew the family.

Towards the end, we were called to CPR in progress by the caregiver. Her husband was on scene and although we had all seen the POLST form many times in our runs to the residence and the pt had long before lost the ability to make an informed decision, the husband told us that her status was full code and said the POLST had been revoked. It hadn't. But, we couldn't corroborate her code status at the hospital and without the form (which he had hidden prior to our arrival) we gave her full code treatment. She arrived at the ER with a pulse, assisted respirations and died the next day.

Was this a waste of resources, ignoring the wishes of the pt, or other heinous offenses? A case could probably be made for it.. but we chose to see it as honoring the grief of the husband who wasn't quite ready to say goodbye after sharing over 60 years with this woman. Yes the eventual decision was to avoid further interventions to prolong her life but you know what they say.. when the pt is gone.. the family becomes your pt.

 

[KEVD18]

the code was worked, and as a result a brown cloud of epic proportions eminated from the call.

the crew that took the call called the doc who told them to work it(remember, he doesnt know the whole story on the son). they had rosc in the field and went to the H. the patient lingered for a bit in the icu(at a rate of thousands a day). when the hcp was finally gotten a hold of, she tweaked like you read about. the pt was removed from life support and promptly kicked off, leaving one hell of a wake.

there were meetings and reports and all sorts of junk over this. after it was determined that the son was of inadequate mental competence, it really hit the fan. the service(i wish for the life of me i could remember which it was. they are defunct now though, so its pretty much irrelevant) pawned it off on the olmc doc stating that they were only doing what the doctor told them too(the nuremburg defense), who tried to kick it back down to the crew since they didnt tell him the brother was retarded. the crew kicked it back up stairs since they didnt know the about the brothers condition and therefore were acting in good faith with orders from a doc who was as informed as he could have been.

the end result was no punitive action against any of the providers and what i can only imagine was a healthy check to the daughter. this si just one of the many examples of how the mass comfort care system is screwed up. this case was maybe as many as a dozen years ago, although my memory is a little hazy on the specifics. i wasnt involved personally, but a good freind of mine was on the rig that took the call.

its a damned if you do, damned if you dont situation.

 

[KEVD18]

...honoring the grief of the husband who wasn't quite ready to say goodbye...

and here we have the fundamental problem in this and many other discussions.

 

[boingo]

If the DNR is valid then the arrest doesn't get worked. Unless it appears forged, is missing, or otherwise appears not legit, its a legal document stating the patients wishes, and a family member, other than a legal HCP or guardian cannot over ride it. I suppose if the family member where to claim that they are the patients guardian or HCP I'd take their word for it, but otherwise its an emotional family member who hasn't come to terms with the patients decision, which is clearly noted by a signed, legal document.

 

[PotatoMedic]

What it seams that I am getting from all the responses in general is

• know your local laws and protocols.
• If in doubt resuscitate.
• talk to medical control and document extensively in odd situations.

Thank you all for you input and the more to come (if any). I'll make sure I ask a similar question when we get to Advanced Directives and DNR's.

 

[BossyCow]

If the DNR is valid then the arrest doesn't get worked. Unless it appears forged, is missing, or otherwise appears not legit, its a legal document stating the patients wishes, and a family member, other than a legal HCP or guardian cannot over ride it. I suppose if the family member where to claim that they are the patients guardian or HCP I'd take their word for it, but otherwise its an emotional family member who hasn't come to terms with the patients decision, which is clearly noted by a signed, legal document.

if the document is there and you see it... but.. the husband in my case destroyed the document prior to our arrival. Not about to jump all over a highly emotional senior citizen that just happens to be a co-worker's grampa over an issue that is best handled by the ER staff and the family members who met him at the ER. Oh.. and into the equation.. the husband was Japanese and though he spoke fluent English would lapse into Japanese and pretend to not understand when stressed.

 

[EMTWintz]

Nope. Simple answer. Every DNR protocol I've seen has basically made it so that any family member can revoke a DNR at any time.

.

So what is the point of getting a DNR anyway? If the document was signed by pt and his/her doctor. What gives a family member the right to deny them that last request. In essence its a worthless peice of paper.

 

[JPINFV]

So what is the point of getting a DNR anyway? If the document was signed by pt and his/her doctor. What gives a family member the right to deny them that last request. In essence its a worthless peice of paper.

Not really. A DNR is a serious decision that when used in deciding medical care (i.e. declining resuscitation) acts as an irrevocable act. You can't decide two days post arrest to resuscitate. As such, it is imperative that all family members are on the same page, just as if a patient was declining other types of medical care on religious or cultural reasons. What if in the patient's final minutes verbally rescinded the DNR order to a relative? EMS providers arriving post arrest have no clue to any conversation that did or did not occur prior to arrival. Furthermore, not all arrests are witnessed by family members.

 

[EMTWintz]

What if in the patient's final minutes verbally rescinded the DNR order to a relative?

This is why I think that people who are looking into DNR's especially the terminally ill need to go thru mandated counciling. Now before anyone jumps my butt, hear me out. Signing a DNR is a BIG deal not to be done in haste. Most people when they find out they are terminal decide they jump into requesting DNR's. If this is something they really want to do, they should have to go thru some sort of class with an expert that can FULLY inform them and their family's the ins and outs. Much like hospice. Studies show that those with family members who are on hospice are more prepared for whats to come and have an "easier" time coping with the passing of their loved ones. IMO this would work well with DNR cases.

 

[boingo]

if the document is there and you see it... but.. the husband in my case destroyed the document prior to our arrival. Not about to jump all over a highly emotional senior citizen that just happens to be a co-worker's grampa over an issue that is best handled by the ER staff and the family members who met him at the ER. Oh.. and into the equation.. the husband was Japanese and though he spoke fluent English would lapse into Japanese and pretend to not understand when stressed.

Hey, if its destroyed or missing, different case. I'm speaking about a legal document in hand.

 

[EeyoreEMT]

Oh the mess-Know your protocols

In Ohio, there are a wide variety of protocols that states what a basic can or cannot do. You have to run under YOUR protocols in your area. In my area under our protocols, If there is a valid DNR in hand, which has to be signed by the pt, or pt's power of attorney, and their physician, you honor the DNR. Our problem here is exactly the opposite, I have had so many codes where the family begs they wouldn't want this or we have a DNR but it's in our safety deposit box at the bank. When first on scene, my partner and I (as we are doing a rapid assesment on pt), asking about down time, history and the like. We are 30 miles from the closest hospital. Odds are, they don't make it. So basically, run the code unless you have VALID DNR, signs or rigor, or if the DNR is dated a awhile back the family insists she/he wouldn't want that, then they would know this - ask if their is a medical poa in place since the paper was signed, if so, and they are not present, run the code. It is better to be questioned on efforts to save a pt, than no effort, like gross neglect.

 

[rhan101277]

Pending medical control contact (since it is an option here), yes. I have no idea what conversation the patient had with her son prior to departing from this world and it is possible that the patient verbally revoked the DNR prior to collapsing.

Same for here, have to contact med control then stop.

 

[MRE]

MA protocols do not require proof of legal guardianship, and implicitly require that the family be accepting of the decision to die without resuscitation attempts.

I did my basic in MA 2 years ago and this is what we were taught. Any reason to disbelieve the validity of a DNR (including family members intervening and verbally revoking the DNR). We were also told to err on the side of resuscitation.

This hasn't happened to me yet, but I'm not looking forward to it.

 

[maxwell]

scenariobtw this is a real call)

you respond for the unresponsive at a private residence.

u/a you find an elderly female supine and unresponsive. assesment reveals a pulseless and apneic patient. there is a double signed and non expiring cc/dnr form present listing a female nok as the hcp/guardian. this person is not present on the scene.

a distraught male person identifying himself as the patients son(the person who handed you the blue paper) asks, the demands recusitative efforts. fwiw, this person is in fact the patients son, but he has a cognitive developmental disability that isnt immediatley apparent due to his hysteria.

the nok is not able to be live contacted.

the resolution of this case will be with held pending comments.


the question(directed mainly at the massachusetts certified dissenters, but open to anyone with very closely similar protocols):

do you work this code?

Nope, I would not work this code. My focus would turn to the son.

 

[EeyoreEMT]

good one

These calls suck. First, I would have to verify that the possible doa is in fact the female who is listed on the DNR sheet as the person who doesn't want to be "brought back". As I, or my partner would be assessing the pt, I would talk with the son for any type of identification on that person, driver's license, some type of photo ID to cover our butts, it case it is the wrong person. If in fact the person, who has coded, is the person on the VALID DNR, CPR would not be started, we would then work on our second pt, the hysterical son, while we wait for the coroner, which living here, takes anywhere from 1-3 hours. Per protocols, we have to have confirmation of assystole in all 3 leads which is printed to validate records. (this would have been done when we first entered the house regardless if there is a DNR or or not)