Dnh/dnr

[jemt]

So i transported back to a nursing home a patient off of Dialysis and I could tell she was going down hill when I was transporting. So we get to the nursing home and the nurse is trying to get her attention but shes not responding at all and barely opening her eyes. I ask the nurse if she wants us to take the pt to the E.R. but the nurse says she is do not hospitalize/DNR.

Now my question is how does a DNH work? Can the patient be in visible/audible distress/pain and they just leave the pt to suffer?


Thanks.

 

[Lady_EMT]

I've never heard of "do not hospitalize" before...

But DNRs are different for each patient. Some may not want any preventative measures, while others will allow some measures, but don't want to be on life support. It depends on this pt's history and DNR details as to what you can do to help this pt.

Sometimes, people just want to die. They want their time to come, and they want to go peacefully, not with someone breaking every rib and jamming a tube down their throat. It may be difficult to watch, but it's what they want.

I know an EMT who saw someone code, and because they had a DNR, the EMT had to sit back and watch. He was a firefighter to begin with, and against EMS, and after being forced to sit back and watch someone die, he threw in his towel and decided it wasn't for him.

 

[WoodyPN]

I would have simply ensured the patient wasn't feeling any pain, to the best of my provided ability.

As LTC goes, it depends on a lot of things. Where I am, its all or nothing, we either do everything, i.e. full code, or a no code.

Ive had one person who was a full code one minute, his family goes up front to see S.S. and he codes. As the 911 crew is walking in the door and were working on him, the family and the social worker walks in with the order and tells us to stop. That wasn't fun.

 

[PFD2171]

Dnh

It would depend on state laws but as I understand it the DNH/DNR is applicable as long as the patient is a resident of that facility including transfers from and to that facility. It takes family to override that order.

 

[Aidey]

It definitely isn't unheard of. In places that use POLST forms there is often a palliative care/comfort care section that specifies not to transport the patient unless their comfort needs can not be met at their current location.

 

[medicdan]

DNR/DNI/DNH orders are very common around here. While we have a standardized DNR order in MA (Comfort Care), they are testing a Medical Orders for Life Sustaining Treatment (MOLST-MA)-- which details well the patient or their family's requests. In some situations, they family will allow for treatment and perhaps transport for non-life threatening illnesses, if they increase comfort or decrease pain (if the patient falls and breaks their wrist, they want to have it splinted/castted and get pain relief, and it's unrelated to the end stage cancer)

 

[ArcticKat]

We moved from the DNR concept some time ago because it was too limiting. Instead we have an Advanced Care Directive in which the client is able to list specifically what procedures he or she wants to have performed. For example, they may choose to be intubated and ventilated, but if their heart stops we are not to conduct CPR. If they acquire a treatable illness with a good prognosis they can be treated, but if the prognosis is poor, then no treatment. Stuff like that.

 

[JPINFV]

Can the patient be in visible/audible distress/pain and they just leave the pt to suffer?


Thanks.

Depending on the situation, yes, and it's not entirely like transporting the patient to the hospital is going to change anything but the room number.

 

[EMTSTUDENT25]

How often do you guys come in contact with a DNR? We were told in school that there are many forms which are not filled out correctly, making them invalid. Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?

 

[JPINFV]

How often do you guys come in contact with a DNR? We were told in school that there are many forms which are not filled out correctly, making them invalid. Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?

Came in contact with them often running IFT, as in probably one every other shift at a minimum, and every shift wasn't too uncommon.

Yes, many of them aren't filled out with the physicians signature. However, the area I worked in included a provision to withhold or withdraw resuscitation on verbal request from an immediate family member.

 

[Tigger]

How often do you guys come in contact with a DNR? We were told in school that there are many forms which are not filled out correctly, making them invalid. Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?

Almost every shift I'd bet for an actual DNR. Most patients transferred from sort of assisted living facility had some sort of directive that went with them during transport even of it only told us they were a full code. I'd try to make sure I had their directive before leaving if it wasn't included.


Sent from my out of area communications device.

 

[Sandog]

Came in contact with them often running IFT, as in probably one every other shift at a minimum, and every shift wasn't too uncommon.

Yes, many of them aren't filled out with the physicians signature. However, the area I worked in included a provision to withhold or withdraw resuscitation on verbal request from an immediate family member.

Verbal request from a family member means squat... Perhaps you spoke in error? If it is as you say, I would love to see the civil code permitting this.

 

[JPINFV]

Verbal request from a family member means squat... Perhaps you spoke in error? If it is as you say, I would love to see the civil code permitting this.

IV. DEFINITIONS:
F. “Immediate Family” means the spouse, adult child(ren), parent of a patient, adult sibling, or domestic partner (pursuant to Section 297 of the Family Code).

...

D. EMS personnel may accept a verbal request to withhold or withdraw resuscitative measures under the following circumstances:

3. Immediate family, present at the scene, may decline resuscitative measures on behalf of the patient.

http://ochealthinfo.com/docs/medical/ems/P&P/330.51.pdf


Can a family member in your system verbally request that you disregard a DNR? Considering how common it is to find incomplete or missing DNRs, especially with patients on home care, this to me is a very sensible protocol.

 

[Sandog]

http://ochealthinfo.com/docs/medical/ems/P&P/330.51.pdf


Can a family member in your system verbally request that you disregard a DNR? Considering how common it is to find incomplete or missing DNRs, especially with patients on home care, this to me is a very sensible protocol.

Holy Crap, this statement floored me.

EMS personnel may withhold or withdraw resuscitative measures when presented with a Do Not Resuscitate (DNR) directive or order, as long as it can be reasonably determined that the patient is the subject of the document. EMS personnel may also withhold or withdraw resuscitative measures for patients without DNR documents when immediate family is on scene and they desire to make a unanimous decision to withhold resuscitation.

Glad I do not have a million bucks. This just seems so wrong to me. You convinced me that you are right, but, holy cow, I think it is wrong. Say I wreck my car and a family member wants my house, "Yeah dude, he wants no help man, let him die" Am I interpreting what you posted correctly? Surely there must be a advanced directive in place. Gee, this just seems whacked.

This totally goes against what I was taught in school. Wow, is all I can say.

 

[JPINFV]

Holy Crap, this statement floored me.


Glad I do not have a million bucks. This just seems so wrong to me. You convinced me that you are right, but, holy cow, I think it is wrong. Say I wreck my car and a family member wants my house, "Yeah dude, he wants no help man, let him die" Am I interpreting what you posted correctly? Surely there must be a advanced directive in place. Gee, this just seems whacked.

This totally goes against what I was taught in school. Wow, is all I can say.

Oh, noez. The EMT-B classroom isn't the end all, be all of medicine?

As to the first part of your post, there's always this:

"F. Base contact should be made and the Base Physician consulted and resuscitation should be initiated:

1. If there are any questions regarding validity of the DNR order, or
...
5. If there is disagreement among family members regarding the withdrawal of resuscitative measures, or

6. Anytime EMS personnel have concerns or require assistance."

Pick any of those three if you think that the patent's best wishes aren't being looked after. Resuscitation is not always in the best interest of the patient.

There's a material difference between the 50 year old in a car accident and the 70 year old with end stage lung cancer who misplaced or never considered getting a formal DNR because they assumed that they, or their family, could actually communicate their wishes with the professionals providing medical care.

 

[BEorP]

Holy Crap, this statement floored me.


Glad I do not have a million bucks. This just seems so wrong to me. You convinced me that you are right, but, holy cow, I think it is wrong. Say I wreck my car and a family member wants my house, "Yeah dude, he wants no help man, let him die" Am I interpreting what you posted correctly? Surely there must be a advanced directive in place. Gee, this just seems whacked.

This totally goes against what I was taught in school. Wow, is all I can say.

I would encourage you to think a bit more about this. I highly doubt this is being implemented for 37 year old millionaires with a witnessed VF cardiac arrest.

First of all, a DNR comes into play when someone is in cardiac arrest. It has nothing to do with "letting someone die" since they are already dead physiologically. The chances of a successful resuscitation are quite low as I'm sure you know.

Secondly, the patient who this directive are most likely used for is someone:
- who is old
- who wouldn't have wanted resuscitation but never put their wishes down on paper
- where "successful" resuscitation would win them a stay in ICU and then probably a more drawn out death


We need more EMS systems where providers are not forced to attempt futile resuscitations that the patients never would have wanted.

 

[LondonMedic]

A 'Do Not Hospitalise' order on someone who's having dialysis? Really?

 

[CAOX3]

Removed

 

[MonkeySquasher]

..... they are testing a Medical Orders for Life Sustaining Treatment (MOLST-MA)-- which details well the patient or their family's requests.

Oh. The MOLST was, I believe, created and piloted near me in Rochester NY. Since then we're finding them more and more in this area. Prehospitally, I like them, as they lay out exactly what the patient's wishes are, much more precise than a DNR/DNI.

How often do you guys come in contact with a DNR? We were told in school that there are many forms which are not filled out correctly, making them invalid. Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?

As others have already covered, there's many factors. The patient may have a DNR that isn't signed, or is outdated, or is lost, or a photocopy (we're supposed to have the original). Or maybe the family suddenly tries to recind the DNR because they're thinking with emotion and want everything done. Or there's an argument within the family about what to do. I've had all of these situations, and in every one, I just call a doc to get their opinion. In 2/3, we confirmed the patient where they lay, and in the 3rd we did BLS CPR to the ER (next door) to appease the family.

tl;dr - If you have any questions, like in CA, just phone your Med Control and paint an accurate picture of patient presentation to the doc. They won't steer you wrong.

 

[WickedGood]

How often do you guys come in contact with a DNR? We were told in school that there are many forms which are not filled out correctly, making them invalid. Also, if the order is not physically in front of you with a docs signature, you are to continue care until its provided...Do these things happen?

I work for a transport service and about 80% of the people we pick up have DNRs. They usually hand them to us with the face sheet and the rest of the paperwork and we keep it on the clipboard while we transport.

The other thing we have is a MOST form-- Medical Orders for Scope of Treatment. http://www.ncdhhs.gov/dhsr/EMS/pdf/ncmostform.pdf
I have yet to have seen one of these, however.