Dilemma - CPR on pt. with invalid DNR form

[Handsome Robb]

Where's the like button??

 

[Medic Tim]

Where's the like button??

Agreed

 

[Shotzman]

thanks for the responses everyone.
and thanks for finding that coastal valleys protocol for me, i wouldnt have thought to look for something like that, mainly because i was always taught power of attorney and/or a valid dnr form.
yes i am very aware that when it all comes down to it, i know i shouldn't start CPR on someone like this mans situation and the situation i was put in, and his familys request to not resuscitate (prior to the knowledge of the verbal unanimous decision of on scene family members), its a moral dilemma, and ultimately it seemed quite obvious that he shouldnt be brought back HAD he coded. the guys mind was gone, alert to painful stimuli only and incomprehensible/inappropriate words (though he was still with it enough to shout "bathroom" and forcibly try and stand up to get to the bathroom, but thats besides the point) but its quite early in my career and its nerve racking thinking id stray from protocol rather than what I think is necessary to be done ( or not be done technically in this case ). How closely does one need to stay true to protocol in a situation such as this

 

[joshrunkle35]

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.

They're not a DNR patient. They don't have a valid DNR.

ETA: Someone's life is not a light thing. If they wrote, "Please let me die." on a napkin near their bed, would you do it? Because it's effectively the same thing.

 

[chaz90]

They're not a DNR patient. They don't have a valid DNR.

ETA: Someone's life is not a light thing. If they wrote, "Please let me die." on a napkin near their bed, would you do it? Because it's effectively the same thing.

They are a DNR patient! I'd call in to Medical Control and let them know I was withholding CPR, but I would absolutely withhold CPR. Hospice-Check. Terminal Cancer-Check. DNR-Check (excepting the proper physician's signature)-Check.

 

[Medic Tim]

thanks for the responses everyone.
and thanks for finding that coastal valleys protocol for me, i wouldnt have thought to look for something like that, mainly because i was always taught power of attorney and/or a valid dnr form.
yes i am very aware that when it all comes down to it, i know i shouldn't start CPR on someone like this mans situation and the situation i was put in, and his familys request to not resuscitate (prior to the knowledge of the verbal unanimous decision of on scene family members), its a moral dilemma, and ultimately it seemed quite obvious that he shouldnt be brought back HAD he coded. the guys mind was gone, alert to painful stimuli only and incomprehensible/inappropriate words (though he was still with it enough to shout "bathroom" and forcibly try and stand up to get to the bathroom, but thats besides the point) but its quite early in my career and its nerve racking thinking id stray from protocol rather than what I think is necessary to be done ( or not be done technically in this case ). How closely does one need to stay true to protocol in a situation such as this

That will depend on your medical director and location. Where I work we are expected to deviate from our clinical guidelines if it is in the best interest of the pt. we also do not call for orders. We can call a doc to consult a treatment plan we have already formulated. If I had ran a full code on this person the call would have been flagged and I would have been sent for remedial training.

That is for my area though. It is important to know you company and state policies and to know what is expected of you. This job can be very tough, especially if you are new. I hope you don't think we are all jumping on you here. We are offering some constructive criticism and an outside view.

 

[Medic Tim]

They are a DNR patient! I'd call in to Medical Control and let them know I was withholding CPR, but I would absolutely withhold CPR. Hospice-Check. Terminal Cancer-Check. DNR-Check (excepting the proper physician's signature)-Check.

Maybe this is another regional difference but everywhere I have ever worked... States and Canada. To be accepted into hospice = you had DNR .

 

[unleashedfury]

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.[/QUOTE]

I'm sure it varies from region to region, But for a medical command facility in our region, medical command report with requests or doctors orders must be done via a recorded line. our daily reports can be done over county frequency but to get orders you must go through cellphone or Medcom on recorded line.

 

[Handsome Robb]

They're not a DNR patient. They don't have a valid DNR.

ETA: Someone's life is not a light thing. If they wrote, "Please let me die." on a napkin near their bed, would you do it? Because it's effectively the same thing.

If you really wanna try and argue that let's do it but he's in the process of getting the DNR paperwork done, going home on hospice and family wants nothing done. In a situation like you described with the napkin it's totally different. This patient has a terminal disease process. Let him die the way he wants to. People die, it's part of life. Unfortunately in EMS classes they tend to teach you have to save everyone, which is not the case. Anyone ever though that honoring a patient's last wishes and letting them die rather than resuscitating them and subjecting them to further pain and suffering is actually saving them? I know I have.

That's a patient you don't start resuscitation on. I have a protocol that if I can't make contact I can do what's in the best interest of the patient, if I couldn't make base contact in this situation I still would pronounce the patient without any resuscitation efforts.

Now if you do have radio/call service get on the phone with a doc and get orders, OLMC orders are no different than standing orders, provided what is ordered is within your scope of practice.

Does that answer your question at all, OP?

 

[TheLocalMedic]

I don't know how much clearer I can make this; this whole "dilemma" has already been addressed in the area shotzman is working in. That stipulation in the region's protocols about terminating resuscitation at the behest of the family was specifically added to circumvent this exact scenario.

The medical director for CVEMSA, Dr Luoto, has a lot of hospice knowledge and experience, and he would absolutely not advise that this patient be worked. If someone is in cardiac arrest and the family does not want resuscitation (especially since this is a hospice patient), then you should not even begin. The existence of the DNR (albeit without an MD signature) and the family's expressed wishes that the patient not be resuscitated (which were expressed before the transfer was made) absolutely spell out that no resuscitation is to take place.

The protocol does say that you may make base contact, but it is not required. That's thrown in there just in case you aren't totally confident about the situation, but it is generally understood by anyone with any medical training or experience that there would be no benefit to attempting to "save" this already terminally ill and dying patient.

 

[Handsome Robb]

I don't know how much clearer I can make this; this whole "dilemma" has already been addressed in the area shotzman is working in. That stipulation in the region's protocols about terminating resuscitation at the behest of the family was specifically added to circumvent this exact scenario.



The medical director for CVEMSA, Dr Luoto, has a lot of hospice knowledge and experience, and he would absolutely not advise that this patient be worked. If someone is in cardiac arrest and the family does not want resuscitation (especially since this is a hospice patient), then you should not even begin. The existence of the DNR (albeit without an MD signature) and the family's expressed wishes that the patient not be resuscitated (which were expressed before the transfer was made) absolutely spell out that no resuscitation is to take place.



The protocol does say that you may make base contact, but it is not required. That's thrown in there just in case you aren't totally confident about the situation, but it is generally understood by anyone with any medical training or experience that there would be no benefit to attempting to "save" this already terminally ill and dying patient.

I don't think that was directed at me seeing as we agree but just making sure.

I, admittedly, skimmed the thread.

MedicTim: here the only DNR I can honor is a "State of nevada prehospital DNR". Unfortunately hospice =/= valid DNR here. We just released a statewide POLST form so I'm assuming we will be able to honor that as well.

Even if a hospice patient doesn't have the valid prehospital DNR I don't do anything, call a doc and tell them I've got a hospice patient without a valid DNR in cardiac arrest, I haven't started resuscitation and request a time of death. Never had a problem with it, including a 15 year old with end stage ovarian cancer. Took a minute for the doc to understand what I was saying but he didn't have an issue with how I handled it.

 

[TheLocalMedic]

I don't think that was directed at me seeing as we agree but just making sure.

I, admittedly, skimmed the thread.

MedicTim: here the only DNR I can honor is a "State of nevada prehospital DNR". Unfortunately hospice =/= valid DNR here. We just released a statewide POLST form so I'm assuming we will be able to honor that as well.

Even if a hospice patient doesn't have the valid prehospital DNR I don't do anything, call a doc and tell them I've got a hospice patient without a valid DNR in cardiac arrest, I haven't started resuscitation and request a time of death. Never had a problem with it, including a 15 year old with end stage ovarian cancer. Took a minute for the doc to understand what I was saying but he didn't have an issue with how I handled it.

No, wasn't directed at you, it sounds like we're on the same page. It was directed at anyone who was saying that we have an obligation to work a code if there isn't a black and white DNR on hand.

Medicine isn't always black and white, but it's still safe to say that a terminal patient shouldn't get worked. Now, on the other hand, if you run into a situation where there isn't a DNR and you have family urging you to act, then your best bet is to at least begin BLS CPR until you can get a physician on a recorded line giving you permission to stop.

But generally speaking people will understand that their terminally ill family member was going to die soon (even though they were hoping for more time) and an honest conversation with them about the futility of attempting resuscitation may be all that is needed for them to agree that any resuscitation should be terminated.

And just to throw this tidbit in: one of the best pieces of advice I was given was 'people who are kind, caring and compassionate don't get sued'. And it's pretty true. So don't be an authoritative a-hole and arrogantly refuse to resuscitate someone. Instead have a calm, sit-down conversation with the family about the reality of the situation and explain in simple terms what is going on. Even if you were in the right about not working the code, if you sound like a jerk it'll cause resentment and you could wind up with people throwing accusations at you.

 

[mycrofft]

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.[/QUOTE]

I'm sure it varies from region to region, But for a medical command facility in our region, medical command report with requests or doctors orders must be done via a recorded line. our daily reports can be done over county frequency but to get orders you must go through cellphone or Medcom on recorded line.

Good in you have a phone line dedicated to do that and it works.

 

[mycrofft]

Doesn't the whole thrust of this thread boil down to "Does it require a MD's signature to make a DNR kosher, or can a patient simply convey their wishes?" ?

 

[NomadicMedic]

No. It boils down to the transporting EMS provider using common sense and preparing for the situation.

 

[triemal04]

Medicine isn't always black and white, but it's still safe to say that a terminal patient shouldn't get worked. Now, on the other hand, if you run into a situation where there isn't a DNR and you have family urging you to act, then your best bet is to at least begin BLS CPR until you can get a physician on a recorded line giving you permission to stop.

But generally speaking people will understand that their terminally ill family member was going to die soon (even though they were hoping for more time) and an honest conversation with them about the futility of attempting resuscitation may be all that is needed for them to agree that any resuscitation should be terminated.

And just to throw this tidbit in: one of the best pieces of advice I was given was 'people who are kind, caring and compassionate don't get sued'.

I like it that the part of Cali' that you are in has this issue covered; I really, really like that in fact. Unfortunately, many places don't have explicit instructions on what to do in this type of situation, so it still falls to the provider. People just need to remember that someone dying is not always a bad thing, and that often starting a resuscitation would go against what both the patient, and family would want. In essence: if you can't technically withhold CPR but common sense and the family is saying to stop...get ahold of your medical control ASAP. Death is not some big bad terrible foe that we are supposed to be up against, despite what get's taught in to many places. People die. Simple fact of life. Often it is better to leave them be.

The bolded part: be careful with that. As the recent freakshow (leach show) from California shows, not everyone feels that way. This is something that needs to be taken on a case by case basis; if the family is ok with not starting a resuscitation that's one thing...but if they aren't and are very opposed to not doing so AND you don't have protocols in place to address this, the situation is different. Calling medical control is still an option, talking honestly with the family is still an option, and something that should be done, but in the interest of your continued career, you may be out of options. Just something to be aware of.

The last part: fortunately, and unfortunately, very true.

 

[Shotzman]

Yes, at least for California's CVEMSA protocols I'm definitely understanding now. This has definitely put my mind at ease if this situation is to arise again. Thank you! In school we are only taught "no valid dnr? Do CPR. No valid power of attorney? Do CPR" no if's and's or but's, so like I said, I never thought to look that closely at the protocols or that it would have something to say like you brought up LocalMedic! And I didn't think base MD could pronounce someone dead from over the phone and allow you to cease CPR.
Sounds like other states aren't the same, hence the different opinions.

 

[Rialaigh]

What more is a DNR then a legally binding way for a patient to communicate what he or she wants. If they lack a DNR then you use family, what you know about the patient and history, and make a judgement decision on what you think the patient would have wanted.

You do not have to have a DNR to not provide treatment. You only have to have a firm belief that the patient (and family in most states) does not want anything done.

This is the same thing as the patient refusing transport that you think is having a STEMI. So you wait until he becomes unconscious and then you treat and transport....it should be criminal. The patient, while coherent and oriented made a decision about his or her medical care. Don't use "altered mental status" or "unresponsive" as an excuse to play god and do everything for the patient.

 

[Rialaigh]

Doesn't the whole thrust of this thread boil down to "Does it require a MD's signature to make a DNR kosher, or can a patient simply convey their wishes?" ?

And to address this, doesn't the patient convey their wishes all the time about whether they want to be transported or want meds or etc..etc..

In this situation if I heard the patient verbally say to me he didn't want anything done then I don't care if I have a DNR or not...The patient stated his wishes on a medical matter and (especially) if the family is agreeing who am I to play god and provide unwanted treatment and make medical decisions for someone else.

 

[Handsome Robb]

Agreed on all points!