Dilemma - CPR on pt. with invalid DNR form

Shotzman

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so i was in a situation the other day where we picked up a patient to take to a nursing home... going on hospice care. Family thought he was gonna die that day from his liver cancer but ultimately he hadn't and they expected no more than 72 hours for him to live. His respiration's were labored and rapid and slightly irregular, and his skin had just become jaundiced a couple hours before we arrived. I had put him on 5 liters for the comfort while in my care. Anyways, ultimately, we received the DNR from the family that was signed by the patient... but did not have a physicians signature! we called our supervisor to make sure we couldn't honor it and he told us we couldn't without the physicians signature , which we had figured already. On the drive to the nursing home... I sat there thinking to myself, I don't want this guy to die on me and have me work him when he obviously doesn't want to be resuscitated, and how much it sucks that it comes down to a piece of unsigned paper that I have to legally perform CPR on him. And I thought, I could "half-***" the CPR so it works in both parties favors.
Then I thought, that just seems wrong to ever half-*** CPR no matter the situation.

Luckily the drive went fine and uneventful. I just wanted to see what others had to say on this type of situation. :sad:
 

Shotzman

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And I sit here now after typing that wondering if I'm stepping over boundaries thinking that way? Or if bringing up a legal matter up for people to discuss if they'd half *** CPR, am I in the wrong? I'm in a very confused state right now haha if you couldn't tell. I just need opinions on anything on this!
 

MrJones

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Kentucky further complicates the issue by requiring a separate, specific EMS DNR form. Without it, even in the presence of an otherwise 100% valid DNR form, we are required to perform CPR and such if a patient codes during transport. And we invariably get the deer in the headlights look when a Nurse tells us the patient is DNR and we ask for the signed EMS DNR form.
 

Aprz

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If the patient has a durable power of attorney, they could say no CPR? Or if the patient goes into cardiac arrest, pull over, start chest compressions, have your partner trade with you, and then call medical direction to tell 'em the situation.
 

TheLocalMedic

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Hey Shotzman, since you're operating under the Coastal Valleys EMS protocols, check out policy number 7006: Determination of Death in the Prehospital Setting. Section A, subsection 6 heading a. point 7:

Resuscitation may be withheld at family request if there is unanimous agreement between all family members on scene. In such a case the EMT or paramedic may choose to consult with Base MD, however the consultation is optional. If there is any doubt or dissention among family or rescuers as to the appropriateness of the decision to withhold resuscitation, resuscitative efforts should continue as per applicable protocol(s).

Which can be interpreted to mean: If all present family members agree that there shall be no resuscitative measures performed (and that can be ascertained before transport, if they are present in the hospital) then should the patient code en route you shall not undertake any kind of resuscitation.

However, when in doubt, you ought to work that code. While it does present an ethical dilemma, if there is any doubt about whether or not you should act, begin basic BLS CPR, contact base and an ALS provider and go from there. You have to protect your own backside, so provide some form of care until you can confirm that you can stop.

Nobody wants a patient to code during a transfer, but it does happen. It sounds like your patient was pretty imminent anyhow, so if I were in your shoes and they happened to die en route, I most likely would have not undertaken any kind of resuscitation. But I'd have made darn sure before leaving that we had already planned for that eventuality and discussed it with the family to verify that they truly didn't want anything done for the patient.
 
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TheLocalMedic

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I've had a few patients code on me during transfers (apparently I'm the Angel of Death), but only one actually had any form of DNR. The one that did have a POLST form resulted in us simply diverting to the nearest hospital and notifying the coroner to have a LEO meet us at the hospital to take custody of the body.
 

jeepdude911

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This is an easy one. Work him. No M.D. signature, no withholding of care. Don't even think about "half ***" CPR.
 

NomadicMedic

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Or better yet, call your doc on the phone and explain the situation, on a taped line.

Transporting a patient to hospice and working a cardiac arrest on the way is simply ludicrous.

If you believe, by any stretch of the imagination, that working that cardiac arrest while en route to HOSPICE is appropriate in any way, shape or form… Immediately mail your certification back to the agency that issued it and leave EMS.
 

Medic Tim

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This is an easy one. Work him. No M.D. signature, no withholding of care. Don't even think about "half ***" CPR.

This may be true in your area but not everywhere.

Where I work a DNR does not need to be officially valid for us to honour it. We can also take verbal DNRs from family as long as the request seems reasonable.

Know your state rules and company policies. This situation is most likely covered. As a last resort you can always contact your medical director or Med control.
 

JPINFV

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Hey Shotzman, since you're operating under the Coastal Valleys EMS protocols, check out policy number 7006: Determination of Death in the Prehospital Setting. Section A, subsection 6 heading a. point 7:

Resuscitation may be withheld at family request if there is unanimous agreement between all family members on scene. In such a case the EMT or paramedic may choose to consult with Base MD, however the consultation is optional. If there is any doubt or dissention among family or rescuers as to the appropriateness of the decision to withhold resuscitation, resuscitative efforts should continue as per applicable protocol(s).
Sweet... so I don't have to look up the protocol for the OP!

I've had cases where hospice patient didn't have a valid DNR and I went down that route prior to transport. Wrote up a quick DNR on the top of the narrative, have the family member sign it (in accordance with OC EMSA protocol), and away we went.
 

joshrunkle35

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This is simple: don't make life or death decisions for patients. You're not a doctor. The patient might want to live, yet a family member might want their inheritance, and may have fraudulently signed the DNR. You don't know the details.

Apologize. Explain to family. ALWAYS PROVIDE HIGH QUALITY CPR! (What if a different family member found out about the whole thing, said it was his will to live, and now sues you over your incompetence!) Contact medical control and explain the situation. Let them make the decision. You follow their decision (provided it's within scope), then document that you did it because you're following their decision, not because you made a decision of your own. You're not a doctor! I'm assuming you don't carry millions of dollars in malpractice insurance either. That's why we let doctors make the big decisions.
 

jeepdude911

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This may be true in your area but not everywhere.

Where I work a DNR does not need to be officially valid for us to honour it. We can also take verbal DNRs from family as long as the request seems reasonable.

Know your state rules and company policies. This situation is most likely covered. As a last resort you can always contact your medical director or Med control.
This incident took place in CA. If you don't have an MD signature, you don't have a DNR. I know it sounds ridiculous to continue care going to hospice, but legally, in CA we would have to work the patient and proceed to nearest ER or return to originating facility. It sounds like in some areas, these laws are open to interpretation. In CA, they are not, nor are they always reasonable. Even a clean DNR can be invalidated on scene if a family member verbally states for you to intervene. So as you may be a little puzzled to find out, there is almost no such thing as a rock solid DNR in the golden state.
 
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Medic Tim

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This is simple: don't make life or death decisions for patients. You're not a doctor. The patient might want to live, yet a family member might want their inheritance, and may have fraudulently signed the DNR. You don't know the details.

Apologize. Explain to family. ALWAYS PROVIDE HIGH QUALITY CPR! (What if a different family member found out about the whole thing, said it was his will to live, and now sues you over your incompetence!) Contact medical control and explain the situation. Let them make the decision. You follow their decision (provided it's within scope), then document that you did it because you're following their decision, not because you made a decision of your own. You're not a doctor! I'm assuming you don't carry millions of dollars in malpractice insurance either. That's why we let doctors make the big decisions.

Wow. I don't even know where to start with this one.

It is our job to do what is in the pts best interest. A DNR is a very reasonable request in this instance. End stage ca . You seriously think they family might be trying to off their family member but can't wait a few more hours... ? Give me a break.

Being a protocol monkey and not using critical thinking in conjunction with assessment or evaluation for fear of being sued is ridiculous. Why are you basing your treatment off of old war stories and EMS myth. Can you give even 1 example of an EMT or medic being successfully sued for following following the pts and family's wish to die in an end stage ca pt?
I understand that there are areas that require physician contact but it does not take a target off our back like you think it does. You will also get much further with docs when you actually sound like you know what you are talking about...like you know what your doing . Ex is requesting specific orders vs... I don't know what to do... Please tell me...( again I understand there are times when this will happen... Probably more often at the BLS level )

As I mentioned before, most companies have policies that cover these situations. It is your responsibility to know your scope, protocols am company policies.
 

Medic Tim

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This incident took place in CA. If you don't have an MD signature, you don't have a DNR. I know it sounds ridiculous to continue care going to hospice, but legally, in CA we would have to work the patient and proceed to nearest ER or return to originating facility.

I believe someone else posted the area in questions policy. Which is different from what you have written above.
 

unleashedfury

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In that situation I'd call for medical control for further direction

Fact Findings Pt. is being discharged to hospice, Has a DNR prepared not signed by a physician. Family most likely expects the patient to die, Patient may have made the decision already to proceed with hospice care and is expected to die.

Don't half *** anything that leaves you not only open for legal consequences but questions your capabilities as a provider. explain to the Doc that you have a hospice patient that has a DNR form completed and not signed by a physician, family accepts the fact that CPR is to be withheld and allow him to make the call.

Or do your job and divert to the closest ED. I have had a Cardiac arrest that was a "DNR" and it wasn't valid, We proceeded with interventions family arrived and talked with the ED after he had ROSC. They extubated him and allow for comfort measures to take place on the med surg floor.
 

joshrunkle35

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Wow. I don't even know where to start with this one.

It is our job to do what is in the pts best interest. A DNR is a very reasonable request in this instance. End stage ca . You seriously think they family might be trying to off their family member but can't wait a few more hours... ? Give me a break.

Being a protocol monkey and not using critical thinking in conjunction with assessment or evaluation for fear of being sued is ridiculous. Why are you basing your treatment off of old war stories and EMS myth. Can you give even 1 example of an EMT or medic being successfully sued for following following the pts and family's wish to die in an end stage ca pt?
I understand that there are areas that require physician contact but it does not take a target off our back like you think it does. You will also get much further with docs when you actually sound like you know what you are talking about...like you know what your doing . Ex is requesting specific orders vs... I don't know what to do... Please tell me...( again I understand there are times when this will happen... Probably more often at the BLS level )

As I mentioned before, most companies have policies that cover these situations. It is your responsibility to know your scope, protocols am company policies.

I am being a patient's advocate by using critical thinking and realizing that I don't know the whole situation. I realize that no doctor may have ever explained to the patient what a DNR is (hence, no Dr's signature). The patient may not have understood what they signed. There could be a billion different scenarios here, none of which benefit the patient by me following a half-done DNR.

Obviously, if you live in a very specific, small portion of the US that has a different protocol, by all means, follow it.

The reality is not that following what a textbook says to do makes you a "protocol monkey", the reality is that as the patient's advocate, you have to realize that there are dozens of possibilities that this may not be what the patient wants, or that they might not understand what they signed. As a patient's advocate, it is in their best interest for me not to follow an invalid DNR. I do follow the protocol not as a "monkey", but as a well-thought-out solution to a problem that I recognize that I don't have all of the answers to.
 
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jeepdude911

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I believe someone else posted the area in questions policy. Which is different from what you have written above.
TheLocalMedic weighed in on this. This medic is from CA. Shotzman is even from an area of CA that I have worked in prior, and the only prudent course of treatment in CA, especially if this was an IFT, meaning dual EMT crew is CPR, AED, lights and siren.
 

mycrofft

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You're a tech, follow protocols when you can, call for help (MD or supervisor) when you need more. Never treat halfway, that's malpractice and should not be in any protocol (probably isn't).

A resuscitation can always be stopped later. Death…not so much.

PS: the taped phone line thing? Have a second person listen in and identify themselves to the MD; that way you have a witness, and so does the doc.
 

Handsome Robb

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There's no reason you can't honor this patient's wishes, get a doctor involved. You'd be surprised how understanding the big bad MDs really are.

I went on a 93 year old female found in cardiac arrest, unknown down time, asystole on the monitor, no "obvious" signs of death, family doesn't want anything done.

Partner does hands only CPR, I call a doc and tell them exactly what I just told you, time of death everyone stop. Easy as that.

Mycrofft, I don't agree with what you just said at all. We are there for the patient's best interest and to be a patient advocate. Not some technician blindly following protocols. That is the EXACT attitude we've been working hard to drive out of EMS, so please don't continue to go spreading misconceptions like that about EMS to our newer providers because when you teach them bad habits it's that much more difficult for us to break them of it and teach them the right way.
 
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chaz90

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There's not a chance I'm initiating any kind of resuscitation on a pulseless and apneic DNR patient going to hospice. This patient has made his wishes clear, and I'm not going against them. For anyone to stand behind "protocol" and say resuscitation is indicated shows they are entirely too reliant on black and white words on paper and not the gray generalities that are day to day life in medicine and life.
 
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