Dilemma - CPR on pt. with invalid DNR form

[mycrofft]

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

Sure.

 

[triemal04]

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.

It's funny...I used this hypothetical scenario on another EMS website; what are you going to do when you attempt to treat the patient who, after being informed of the risks and adamantly refuses treatment, becomes unresponsive, and the family begins to scream at you to not touch them?

About the only response I got was the sound of crickets...

People really need to think about this and be ready for it.

 

[Handsome Robb]

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?" ?

Is that not exactly what we are all talking about?

 

[mycrofft]

Is that not exactly what we are all talking about?

I thought so. But I've certainly been wrong before.

Probably will be again tomorrow before supper.

 

[TheLocalMedic]

Is that not exactly what we are all talking about?

I think it's more along the lines of the being given an incomplete DNR without an MD signature and having a patient who isn't really coherent enough to ask directly. Honestly though, if the family says "no code", then that's what I'm going to do, regardless of whether or not the DNR isn't tip-top.

 

[Handsome Robb]

I think it's more along the lines of the being given an incomplete DNR without an MD signature and having a patient who isn't really coherent enough to ask directly. Honestly though, if the family says "no code", then that's what I'm going to do, regardless of whether or not the DNR isn't tip-top.

I definitely agree. I'm not fighting with a family and working a code.

 

[mycrofft]

I think it's more along the lines of the being given an incomplete DNR without an MD signature and having a patient who isn't really coherent enough to ask directly. Honestly though, if the family says "no code", then that's what I'm going to do, regardless of whether or not the DNR isn't tip-top.

I'll drink to that.:beerchug:

 

[yowzer]

My protocols would let us withhold resuscitation attempts in that case, valid DNR/POLST or not. If a patient has a terminal illness and family doesn't want anything done, we're supposed to respect their wishes.

 

[CentralCalEMT]

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.

While that might be true in a lot of places, remember CA lets EMS be run at the local (county or combined county) level. State EMS guidelines are just that, guidelines and individual counties run things differently.

It's amazing how even in the same state, and yes I am aware this is crazy CA, protocols can differ greatly between EMS administrative areas. Where I work, which is part of the 4 county CCEMSA system, we have broad definitions of what a DNR is. There is even a guideline that states a DNR "may or may not be signed by a physician." We can accept internal DNRs from long term care facilities as long as they are short and to the point. We can accept "Do not resuscitate" written by a MD in a patient's chart as a physician order as well as other commonly accepted forms. We can also accept DNR medallions and even oral DNRs from the patient before they code or the immediate family members over 18 if they are involved in direct patient care. (That way a long lost cousin cant resurface and try and get CPR withheld) Personally, I believe these guidelines are ethical and put the desires of the patient first. Having all these guidelines I personally believe maintains a patient's dignity. Of course any and all of these can be revoked by a patient, caregiver, family member or base hospital MD at any time.

I would feel horrible initiating ACLS measures or even BLS on a hospice patient because of paperwork confusion. In 2014 any EMS administration that does not address with some detail DNR/advanced directives and take into account all the circumstances might be behind the times.

 

[Handsome Robb]

I'm gonna say it again. Pick up a freaking telephone or turn in your patch.

I'm done being nice about it and listening to people advocate for violating a person's last and final wishes in regards to their healthcare and remains.

We are patient advocates. Patient advocates do what they have to to provide what is best for the patient and to honor their decisions in regards to their healthcare.

 

[Kevinf]

What I'd like to know is why it's so difficult to fill out a half-page form properly. Without hyperbole, roughly 80% of the DNR forms I receive are not valid for one reason or another. They aren't that complex! This is coming from hospice, hospitals, and ECFs... they should know how to fill one out.

Legally, it's not a bad idea to have your paperwork in order before transporting a patient from a care facility... I.e. transfer of care signature, signed for any of the patient's narcotics, valid DNR, etc. Going to agree that you really shouldn't be doing CPR on a terminal patient. It would just be nice if we got proper forms once in awhile.

 

[Handsome Robb]

What I'd like to know is why it's so difficult to fill out a half-page form properly. Without hyperbole, roughly 80% of the DNR forms I receive are not valid for one reason or another. They aren't that complex! This is coming from hospice, hospitals, and ECFs... they should know how to fill one out.

Legally, it's not a bad idea to have your paperwork in order before transporting a patient from a care facility... I.e. transfer of care signature, signed for any of the patient's narcotics, valid DNR, etc. Going to agree that you really shouldn't be doing CPR on a terminal patient. It would just be nice if we got proper forms once in awhile.

I agree, there's no argument there.

However the lack of a valid DNR can be easily circumvented.

Unfortunately calling for orders seems to have this stigma of "you don't know what you're doing." People at my agency brag about not ever calling, which per protocol we rarely have to. I call all the time to go around my protocols to provide appropriate and compassionate care just like is hope someone would do for me, my family or my friends.

 

[Akulahawk]

I agree, there's no argument there.

However the lack of a valid DNR can be easily circumvented.

Unfortunately calling for orders seems to have this stigma of "you don't know what you're doing." People at my agency brag about not ever calling, which per protocol we rarely have to. I call all the time to go around my protocols to provide appropriate and compassionate care just like is hope someone would do for me, my family or my friends.

If I'm calling for orders, it's going to be for the reason above (get around an invalid DNR), to create a custom care plan for a patient that doesn't fit any protocol that we have, or to be able to go past a particular pre-determined point in a given protocol. Our transports are usually so short that we almost NEVER had to call for base orders to go beyond that big black line...

 

[Handsome Robb]

If I'm calling for orders, it's going to be for the reason above (get around an invalid DNR), to create a custom care plan for a patient that doesn't fit any protocol that we have, or to be able to go past a particular pre-determined point in a given protocol. Our transports are usually so short that we almost NEVER had to call for base orders to go beyond that big black line...

Agreed. My transport times are generally <10 minutes but in a situation like you described, with a patient that doesn't fit into a protocol, it's not a big deal to start the ball in motion, delegate things then call while your partner and fire packages and loads the patient.

Maybe I didn't articulate what I meant very well.

 

[SandpitMedic]

My local protocol:

DO NOT RESUSCITATE

1. All patients with absent vital signs who do not have conclusive signs of death (refer to Prehospital Death Determination protocol) shall be treated with life-resuscitating measures unless EMS personnel are presented with a valid Do-Not Resuscitate (DNR) Identification or Order.

- A valid DNR Identification is a form, wallet card or medallion issued by the Southern Nevada Health District, Nevada State Health Division or an identification issued by another state indicating a person’s desire and qualification to have life resuscitating treatment withheld.

- A valid DNR Order is a written directive issued by a physician licensed in this state that life-resuscitating treatment is not to be administered to a qualified patient. The term also includes a valid do-not-resuscitate order issued under the laws of another state.

Note: Verbal instructions from friends or family members do NOT constitute a valid DNR.

2. In preparation for, or during an inter-facility transfer, a valid DNR Order in the qualified patient’s medical record shall be honored in accordance with this protocol.

3. If the EMS provider is presented with a DNR Order or Identification, he shall attempt to verify the validity of the Order or Identification by confirming the patient’s name, age, and condition of identification.

4. The DNR Order or Identification shall be determined invalid if at any time the patient indicates that he/she wishes to receive life-resuscitating treatment. The EMS provider shall document the presence of the DNR Order or Identification and how the patient indicated that he/she wanted the Order or Identification to be revoked. EMS personnel shall relay this information to any subsequent medical providers including but not limited to flight crews and staff at the receiving medical facility.

5. Once the DNR Order or Identification is determined to be valid and has not been revoked by the patient, the emergency care provider shall provide ONLY supportive care and withhold life-resuscitating measures.

6. EMS personnel will document on the PCR the presence of the DNR Order or Identification. Documentation should include the patient’s name, physician’s name and identification number, which are found on the DNR Order or Identification.

7. An EMS provider who is unwilling or unable to comply with the DNR protocol shall take all reasonable measures to transfer a patient with a DNR Order or Identification to another provider or facility in which the DNR protocol may be followed.

 

[SandpitMedic]

You see my protocols. I'm pretty much covered. Even subsection 7 says if I'm unwilling or unable to comply with the DNR to transfer them to a facility/provider that will/can.

Now, I side with Robb. With all things considered: No way am I going to start resuscitation on an end stage ca patient who was given 72 hours to live with a partial DNR and family agreeing to withhold. HOWEVER, before that patient is on my gurney that paper is getting signed by a physician. I will avoid the issue by solving it right there. MD at the facility, fax it, or whatever- I'm getting it signed or I am calling for OLMC and explaining the situation and documenting an OLMC MD order to withhold in the event of cardiac arrest on the Protocol Deviation form we are provided and in my chart. What's the 15 minutes it takes to get that done? There's no reason to load and go. Get it taken care of before you transport. Problem solved. Protocol deviation forms are available for those grey areas... It's expected for you to do what is in your patients best interests- always.

Now as we've clearly displayed, there are different protocols in different places. Follow them, or contact medical direction. Families and such may not be so "ready" when their loved one actually stops breathing, and may become unpredictable and/or irrational. Or they may claim they weren't in the proper state of mind due to emotional distress. And you're the professional paramedic in the room who has to do something and is expected to act to save a life (clearly to the lay person)... Better think quick. Lets not forget- this is CA we are talking about. You could get sued regardless, and you probably will if things go even a hint towards the sour side. Even if you are innocent or found to be acting in the pt's best interests and not negligently you're going to go bankrupt defending yourself possibly. It's unlikely to reach that level, but you don't want to be on CNN. This is a HOT topic recently, in CA, TX, and elsewhere, and if you follow the news you'll see there are a few of these similar cases going on right now.

Again, this is California were talking about. The state that brought you this little case- remember: http://thelegalguardian.com/good-samaritanism-died-in-a-car-crash/

In case you forgot, a lay person friend helped rescue a victim from a (supposedly smoking/smoldering) car wreck causing her to be permanently paralyzed... And was sued... And lost in the CA Supreme Kangaroo Court because the Good Samaritan law is for Emergency MEDICAL Care, not to include "rescuing" with the word "medical."

I know that has nothing to do with EMS or the OP's topic, but it brings to helm the ridiculousness of the CA legal system. Regardless of local law/protocol; now put an EMT or Parmedic in those shoes in our "dilemma" and wham-o. The daughter, not on scene was stuck in traffic, did t get to say goodbye, and now shes calling "channel 3 on your side." Instant headlines and legal pundits who know nothing about what it's like to care for a dying patient or a grieving family or to be placed in that position of having to choose to begin CPR or deny CPR are now Monday morning quarterbacking your play, and likely every play you've ever made. Effectively ruining your name and career. You'll have supporters and opposition, but in CA it's a toss up between evil lawyers and common sense deciding your fate.

Just, ew. What an icky scenario. That will go down differently in any given jurisdiction. Your best bet is to always do what's best for your patient, and always cover your butt at the same time. Get it taken care of before transporting, and keep your name out of the spotlight. Just avoid all that rambling I just did becoming your reality.

OP, lucky for you, it went smoothly.If it had, local protocols backed you, and the family was "normal."

 

[SandpitMedic]

Then you have a case like this:

http://www.theledger.com/article/20130411/NEWS/304115037#gsc.tab=0

Granted, not the same exact scenario, but DNR related. No DNR form (valid or not) and care was intiated, and now people are getting sued. I didn't see EMS getting sued though, because they likely followed protocol and worked the patient despite her being a (allegedly) known DNR at the facility she was picked up from.

 

[SandpitMedic]

Another perfect, and more closely related example. How much do you think this doc's legal fees amounted to? Probably more than you'll make in 10 years as a paramedic considering this case went all the way to trial. Perfect example of the family doing an about-face when the moment arises, and sueing the bejesus out of you. Even after expressed verbal AND documented consent by the patient AND family.

http://www.renalandurologynews.com/...ng-a-do-not-resuscitate-order/article/273249/

The article:

Dr. L, 45, a pulmonologist, was summoned to a hospital emergency department (ED) because of the severity of a particular case. The patient, Mr. Y, 78, was suffering shortness of breath.

He also had a long list of serious medical conditions, including a recent intracranial hemorrhage. A computed tomography scan revealed massive blood clotting in Mr. Y's lungs, affecting the flow of blood to his left leg. The scan also showed congestive heart failure. Dr. L determined that the only option was surgical, but the patient's odds were poor.

Mr. Y was alert, able to talk, oriented to place and time, and understood what was happening. The only option, Dr. L said, would be to surgically insert a filter in Mr. Y's groin. He told the patient there was a good chance he would not survive the operation. Dr. L asked Mr. Y if he thought about whether he would want “heroic measures” taken if he went into cardiac arrest. The patient sat up straighter in bed, shook his head strongly, and said, “No, I don't want that. I'll have the operation, but if something happens, just let me go.”

“Do you understand what he's saying?” Dr. L asked the family.

“Yes,” one of the children answered. The others nodded.

Dr. L wrote the following in the patient's chart: “Do Not Resuscitate. I discussed with the patient whether he would want CPR, heart defibrillation, or mechanical ventilation. He was quite clear that he did not wish this. I then addressed with the family members in attendance why I did this and whether they understood, and all expressed their agreement.”

The procedure itself went well, but hours later when walking to the restroom he suddenly stopped breathing and collapsed. A nurse's aide began CPR and called code while the horrified family looked on.

Dr. L was in the hallway when he heard the code. He rushed to Mr. Y's room to find the aide performing CPR.

“Stop!” he instructed the aide. “He has a DNR order.”

The aide stopped performing CPR, and Dr. L tried to get the family out of the room. Mr. Y's daughters were crying hysterically, but his son was shouting.

“Do the CPR!” yelled the son, frantically. “Give him CPR! I'm his health care proxy! I'm telling you to do it!”

Dr. L had to call several nurses to pull the son out of the room. The physician tried to speak to the son about the DNR order, but the son furiously kept insisting that his father should be resuscitated. During this time, the patient died.

A few months later, the family of Mr. Y hired a plaintiff's attorney and ultimately sued Dr. L for the wrongful death of Mr. Y. The physician met with his defense attorney who felt that the case was strong. Eventually, the case proceeded to trial.

At trial, Mr. Y's family testified about the shock of witnessing their father's death, and how they had unsuccessfully begged the nurses to continue CPR. The son testified that he was the healthcare proxy for his father, that his father had a living will that had been created two years prior, and that the living will stated that he did want CPR or other resuscitation measures in the event he needed them.

Dr. L testified about his conversation with Mr. Y, and how he had clearly, and in front of his children, told them that he did not want to be resuscitated. The defense introduced medical experts who testified that Mr. Y's prognosis was grim, and that it was very unlikely that he would have left the hospital alive, even in the best of circumstances.

The jury deliberated only briefly before finding Dr. L not liable for the patient's death.

 

[mycrofft]

You see my protocols. I'm pretty much covered. Even subsection 7 says if I'm unwilling or unable to comply with the DNR to transfer them to a facility/provider that will/can.

Now, I side with Robb. With all things considered: No way am I going to start resuscitation on an end stage ca patient who was given 72 hours to live with a partial DNR and family agreeing to withhold. HOWEVER, before that patient is on my gurney that paper is getting signed by a physician. I will avoid the issue by solving it right there. MD at the facility, fax it, or whatever- I'm getting it signed or I am calling for OLMC and explaining the situation and documenting an OLMC MD order to withhold in the event of cardiac arrest on the Protocol Deviation form we are provided and in my chart. What's the 15 minutes it takes to get that done? There's no reason to load and go. Get it taken care of before you transport. Problem solved. Protocol deviation forms are available for those grey areas... It's expected for you to do what is in your patients best interests- always.

Now as we've clearly displayed, there are different protocols in different places. Follow them, or contact medical direction. Families and such may not be so "ready" when their loved one actually stops breathing, and may become unpredictable and/or irrational. Or they may claim they weren't in the proper state of mind due to emotional distress. And you're the professional paramedic in the room who has to do something and is expected to act to save a life (clearly to the lay person)... Better think quick. Lets not forget- this is CA we are talking about. You could get sued regardless, and you probably will if things go even a hint towards the sour side. Even if you are innocent or found to be acting in the pt's best interests and not negligently you're going to go bankrupt defending yourself possibly. It's unlikely to reach that level, but you don't want to be on CNN. This is a HOT topic recently, in CA, TX, and elsewhere, and if you follow the news you'll see there are a few of these similar cases going on right now.

Again, this is California were talking about. The state that brought you this little case- remember: http://thelegalguardian.com/good-samaritanism-died-in-a-car-crash/

In case you forgot, a lay person friend helped rescue a victim from a (supposedly smoking/smoldering) car wreck causing her to be permanently paralyzed... And was sued... And lost in the CA Supreme Kangaroo Court because the Good Samaritan law is for Emergency MEDICAL Care, not to include "rescuing" with the word "medical."

I know that has nothing to do with EMS or the OP's topic, but it brings to helm the ridiculousness of the CA legal system. Regardless of local law/protocol; now put an EMT or Parmedic in those shoes in our "dilemma" and wham-o. The daughter, not on scene was stuck in traffic, did t get to say goodbye, and now shes calling "channel 3 on your side." Instant headlines and legal pundits who know nothing about what it's like to care for a dying patient or a grieving family or to be placed in that position of having to choose to begin CPR or deny CPR are now Monday morning quarterbacking your play, and likely every play you've ever made. Effectively ruining your name and career. You'll have supporters and opposition, but in CA it's a toss up between evil lawyers and common sense deciding your fate.

Just, ew. What an icky scenario. That will go down differently in any given jurisdiction. Your best bet is to always do what's best for your patient, and always cover your butt at the same time. Get it taken care of before transporting, and keep your name out of the spotlight. Just avoid all that rambling I just did becoming your reality.

OP, lucky for you, it went smoothly.If it had, local protocols backed you, and the family was "normal."

Within months of that second appeal (the initial finding was in favor of the defendant, but she lost the two appeals) the state legislature passed language making associated necessary actions part of a GOod Sam's actions, meeting the same criteria for being correct, within training or knowledge, for free, etc.
Rest of reply: you betcha.

Want to hear about messed up legal? On-call medical examiner declared an execution style shooting a suicide in Nebraska once, per my boss.

 

[SandpitMedic]

You never know. Our industry is ripe with lawsuits and a lot of liability.