Dnh/dnr

[Anjel]

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?

We are told by nursing homes they are a DNR all the time. But when transporting that cannot or willnot give us or show us the original.

So if granny decides to circle the drain in my ambulance I have to do every lifesaving measure I can do.

 

[MrBrown]

Locally speaking (significant medicolegal differences than the US) we are expected to honour living wills and advanced directives (including verbal directives)

Brown is a fierce advocate of patient rights and patient choice, if the patient has clearly described their wishes be it written, verbal, in mine or Zulu then who are Ambulance Officers to disregard them? That is inappropriate and unethical.

 

[LondonMedic]

Locally speaking (significant medicolegal differences than the US) we are expected to honour living wills and advanced directives (including verbal directives)

Brown is a fierce advocate of patient rights and patient choice, if the patient has clearly described their wishes be it written, verbal, in mine or Zulu then who are Ambulance Officers to disregard them? That is inappropriate and unethical.

Agreed 100%.

I struggle to understand a medical culture where the discussion is about how best to invalidate and ignore DNRs and force treatment on patients.

 

[MrBrown]

I struggle to understand a medical culture where the discussion is about how best to invalidate and ignore DNRs and force treatment on patients.

For you it depends how much you dislike your Consultant

Speaking of which, Brown may or may not have misidentified you as a Consultant ... should keep that handy, print a copy or something, it will come in handy at the pub

... LondonMedic ... is a Consultant/...BASICS Doctor, he could be quite useful

 

[lightsandsirens5]

Y'all aren't allowed to honor copies? Really?

 

[Anjel]

Nope.

I was asking our CQI person and she said it has to be original.

 

[JPINFV]

Agreed 100%.

I struggle to understand a medical culture where the discussion is about how best to invalidate and ignore DNRs and force treatment on patients.

It's the same thing with everything else. An overriding fear of liability is engrained starting with the first class and it's always better to do something than nothing.

 

[JPINFV]

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.

DNRs also come into play in a peri-arrest situation. I would be very hesitant and reluctant to place an advanced airway in a patient circling the drain just because they hadn't finally passed through the drain yet.

 

[Anjel]

A. EMS providers shall not attempt resuscitation of any individual who meets ALL
of the following criteria:
a. 18 years of age or older
b. Patient has no vital signs. This means no pulse or evidence of
respiration.

c. Patient is wearing a do-not-resuscitate identification bracelet which is
clearly imprinted with the words “Do-Not-Resuscitate Order”, name and
address of declarant, and the name and telephone number of declarant’s
attending physician, if any OR

The EMS provider is provided with a do-not-resuscitate order from the
patient. Such an order form shall be in substantially the form outlined in
Annex 1 or 2 and shall be dated and signed by all parties.

B. A patient wearing a “do-not-resuscitate order” identification bracelet, or who has
executed a valid “do-not-resuscitate order” form, but who has vital signs, shall
not be denied any treatments or care otherwise specified in protocols.

C. If a do-not-resuscitate order form is presented and is not substantially in the form
as outlined in Annex 1 or 2, or is not complete and signed by all parties,
resuscitation will be initiated while Medical Control is being contacted for
direction.

So it doesn't mention anything about originals. So I am not sure. That is out protocol though. It all results in contacting medical control.

But a patients POA and Guardian can verbally request that you not resuscitate IF they can provide the paperwork proving who they are.

I have been seeing a lot of the bracelets lately. Especially in the hospital.

 

[emt1000]

In response to the initial post. Why if you were transporting a patient to a SNF and did have the DNR in hand and the patient started going downhill enroute, then why did you not divert to a the most accessible receiving facility/ER and instead took the patient back to a SNF? If a patient is deteriorating while being transported and you do not have a do not hospitalize order in hand, then the patient needs to go to an ER and not SNF.

I am a major advocate for patient's rights and DNRs but transporting a patient that is deteriorating back to a SNF in hopes of consulting with the nurse there or finding a DNR sounds like bad patient care to me.

 

[jjesusfreak01]

We don't honor copies of the DNR either. If they won't give me an original (you can make multiple originals), then they don't want me to honor the DNR. Nursing home copies tend to be terrible quality anyways, and I have to be able to read the name on the form.

Patients who go downhill during transport (IFT) get a quick diversion towards the hospital and an ALS intercept if its quicker.

 

[JPINFV]

If a patient has a DNR, especially if the patient is on hospice, what is the ED going to do for the patient who is going down hill?

 

[JPINFV]

We don't honor copies of the DNR either. If they won't give me an original (you can make multiple originals), then they don't want me to honor the DNR. Nursing home copies tend to be terrible quality anyways, and I have to be able to read the name on the form.

Then, ideally, you should make a duplicate copy of your PCR for the ED. After all, copies, be them carbon copies or photocopies, are often poor quality. Why should the ED accept care of your patient if you aren't willing to make them an original of your PCR? Oh, and make sure to include enough originals for the floor unit and what ever facility the patient is discharged to.

A DNR is a long term document that is needed in multiple charts. Why should a SNF give you the original when they need the original for their chart? The patient's wishes shouldn't depend on a game of "who has first" and ensure that a single document is properly tracked and handed back and forth.

 

[Anjel]

Then, ideally, you should make a duplicate copy of your PCR for the ED. After all, copies, be them carbon copies or photocopies, are often poor quality. Why should the ED accept care of your patient if you aren't willing to make them an original of your PCR? Oh, and make sure to include enough originals for the floor unit and what ever facility the patient is discharged to.

A DNR is a long term document that is needed in multiple charts. Why should a SNF give you the original when they need the original for their chart? The patient's wishes shouldn't depend on a game of "who has first" and ensure that a single document is properly tracked and handed back and forth.

Its not a personal choice not to honor them. Its policy.

And out pcrs are electronic and.faxed to the ED after we leave.

 

[Anjel]

Also if I can at least see the original and take a copy thats fine. I just need to see it

 

[usalsfyre]

Apparently there's a banner business out there manufacturing counterfeit copies of DNR orders .

Of course, the legislature in my state just set patient choice through advanced directives back 10 years...

 

[jjesusfreak01]

Then, ideally, you should make a duplicate copy of your PCR for the ED. After all, copies, be them carbon copies or photocopies, are often poor quality. Why should the ED accept care of your patient if you aren't willing to make them an original of your PCR? Oh, and make sure to include enough originals for the floor unit and what ever facility the patient is discharged to.

A DNR is a long term document that is needed in multiple charts. Why should a SNF give you the original when they need the original for their chart? The patient's wishes shouldn't depend on a game of "who has first" and ensure that a single document is properly tracked and handed back and forth.

All of our PCRs are digital and (when im working EMS) are immediately available to the hospital once completed. In North Carolina, at least one original DNR is supposed to be kept with the patient. Wherever i'm transporting a patient to needs the DNR just as much as I do.

 

[BEorP]

DNRs also come into play in a peri-arrest situation. I would be very hesitant and reluctant to place an advanced airway in a patient circling the drain just because they hadn't finally passed through the drain yet.

Fair point. What I was more meaning is that a DNR doesn't mean that if someone crashes their car and you get there and (somehow) find out that they have a DNR and a broken leg that you just walk away.

 

[JPINFV]

All of our PCRs are digital and (when im working EMS) are immediately available to the hospital once completed. In North Carolina, at least one original DNR is supposed to be kept with the patient. Wherever i'm transporting a patient to needs the DNR just as much as I do.

The problem is the insanity of the issues surrounding DNRs with EMS. No one else puts so many restrictions and a physician when faced with a valid DNR order, be it a written order in a chart, or the state approved plaid colored form, is going to honor the DNR. I don't understand EMS's obsession with having to be different from everyone else.

 

[JPINFV]

Fair point. What I was more meaning is that a DNR doesn't mean that if someone crashes their car and you get there and (somehow) find out that they have a DNR and a broken leg that you just walk away.

True, however I don't think anything that a DNR order directly restricts would be pertinent to a broken leg anyways. Now if the car accident victim needs to be intubated to protect his/her airway you've ran into a significant problem.