DNR/Advanced Directivies.

[Remeber343]

I have been thinking about this for a little bit, and our shift had a discussion about it the other day. Hypothetical, of course, lets say you are toned to a 70 y/o not breathing found by relatives. I'm sure everyone here is familiar with DNR orders or Advanced Directives. Lets say that the above patient has signed/legal DNR/AD and wishes to not be resuscitated.

I have a few different scenarios for this:

1) You arrive, patient has signed DNR orders, but the family there is frantically screaming and asking you to do everything you can for the patient. It was an unwittnessed arrest, patient was just found. You tell the family you wish to respect the deceased wishes, and you deny any resuscitation attempts. The family become agitated and start to get aggressive.

1a) You arrive, the patient was a witnessed arrested. Same as above, signed DNRs but the family is frantic and becomes agitated and aggressive towards you and your partner.

2) Witnessed arrest, before the patient went into arrest, the family state he said "Don't let me die, I don't want to die yet". Pt has signed DNR.

I'm just seeing what anyone eles opinions/thoughts are on these. I find it somewhat difficult at times. Its a legal document, and you have to respect the patients wishes.

 

[JPINFV]

1: Resuscitate
1a: Move to ambulance, resuscitate
2: Resuscitate


Note: Your best resource is to look up your company/regional/state policy regarding honoring DNRs. Yes, it's a legal document, but you don't know what was said prior, both immediately and in the days/weeks/months leading to the arrest.

 

[Epi-do]

I agree with JP. In all 3 situation you described, it would be best to begin resuscitation, head for the truck, and let the hospital deal with the family.

I have always been told that if the family requests efforts be made, you go ahead and start CPR, despite the DNR. Also, if there are ever any doubts about the DNR or it's validity, start CPR. (This it the policy of my department, mind you.) Especially, if the scene is deteriorating and your safety is becoming an issue. Sometimes, the circumstances dictate that you have to make decisions your wouldn't ordinarily make.

 

[JPINFV]

Another thing. It's easier to stop CPR after having someone discuss the situation with the family members than it is to start CPR after having someone discuss the situation with family members.

 

[Smellypaddler]

I don't know if it is the same in the USA as Australia but what condition does he have the DNR for?

I mean if he has cancer and doesn't want to be resus'd if he arrests as a complication to his cancer it is different to if he arrests due to a FBAO.

If the DNR order is valid and witnessed it doesn't matter what the family want as it is the patients wishes not to be resuscitated. Resuscitated does not just mean saved but means being tubed, have your chest thumped on and lines put in your arms.

If I was on this job I would not start resus and would start talking my way out of the aggressive situation. Failing that I'd go sit in the truck, lock the doors and call for PD backup.

For those of you who advocate starting resus, what do you do if you somehow get a ROSC on scene or before arrival at the hospital?

If that was me and I woke up due to your resus efforts I would be off to my ambulance chasing lawyer and suing the pants off you.

 

[JPINFV]

For those of you who advocate starting resus, what do you do if you somehow get a ROSC on scene or before arrival at the hospital?

If that was me and I woke up due to your resus efforts I would be off to my ambulance chasing lawyer and suing the pants off you.

In this situation, an immediate family member has revoked the DNR, therefore if ROSC is obtained the crew should proceed as normal.

Since an immediate family member has revoked the DNR, you would have no cause for action against the EMS crew.

 

[DesertMedic66]

As long as there is a valid DNR order then I am not going to start CPR. If the family starts to get aggressive then try to talk them down. If that doesn't work then leave the scene and call PD.

If however the DNR order gets lost or destroyed then I will start CPR.

 

[Remeber343]

Since an immediate family member has revoked the DNR.

This brings me to another point, can a family member revoke the DNR? I do not believe A Family member can. POA might be able to, with compelling evidence.
I know my stance on this subject, just trying to get people to think. We dont come across situations like this that often, its good to maul over them every once and awhile.

 

[JPINFV]

This brings me to another point, can a family member revoke the DNR? I do not believe A Family member can. POA might be able to, with compelling evidence.
I know my stance on this subject, just trying to get people to think. We dont come across situations like this that often, its good to maul over them every once and awhile.

What state are you in (and if in California, what county)? The following is, in my experience, a common part of prehospital DNR policies. Maybe "revoked" is a little strong, but it's in effect the same result.

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.

-Orange County Local EMS Agency DNR policy
http://www.ochealthinfo.com/docs/medical/ems/P&P/330.51.pdf

So if I have family members on scene asking me to resuscitate, I've got 3 reasons alone why I should start resuscitation and contact a base hospital.

 

[DesertMedic66]

My policies say nothing about family members so it's not a choice.

 

[JPINFV]

My policies say nothing about family members so it's not a choice.

I know... I was going to reply with a link, but then I read the Riverside protocols and was surprised that they weren't there.

 

[Remeber343]

"So if I have family members on scene asking me to resuscitate, I've got 3 reasons alone why I should start resuscitation and contact a base hospital"

Youre saying that if the family members want resuscitation and there is a DNR order that is there and valid you are going to attempt to resuscitate?

 

[wyoskibum]

Depends on which state you are in. In the wake of the Terry Shivo situation quite a few years back, some states changed their laws to allow the family to supersede DNRs. If you have ant doubt, look up you state statutes.

 

[Cup of Joe]

In NY, we may ignore a valid DNR:

• Any case where there is reasonable evidence to suggest that the DNR order has been revoked or cancelled.
• If the patient is conscious and states that they wish resuscitative measures, the DNR Form should be ignored.
• If the patient is unable to state his or her desire and a family member is present and requests resuscitative measures for the patient and a confrontational situation is likely to result, if the request is denied.
• A physician directs that the order be disregarded.

 

[firetender]

I have been thinking about this for a little bit, and our shift had a discussion about it the other day. Hypothetical, of course, lets say you are toned to a 70 y/o not breathing found by relatives. I'm sure everyone here is familiar with DNR orders or Advanced Directives. Lets say that the above patient has signed/legal DNR/AD and wishes to not be resuscitated.

I have a few different scenarios for this:

1) You arrive, patient has signed DNR orders, but the family there is frantically screaming and asking you to do everything you can for the patient. It was an unwittnessed arrest, patient was just found. You tell the family you wish to respect the deceased wishes, and you deny any resuscitation attempts. The family become agitated and start to get aggressive.

1a) You arrive, the patient was a witnessed arrested. Same as above, signed DNRs but the family is frantic and becomes agitated and aggressive towards you and your partner.

2) Witnessed arrest, before the patient went into arrest, the family state he said "Don't let me die, I don't want to die yet". Pt has signed DNR.

I'm just seeing what anyone eles opinions/thoughts are on these. I find it somewhat difficult at times. Its a legal document, and you have to respect the patients wishes.

I understand this is theoretical but how are you going to know there is a DNR order (signed) unless the family gives it to you? That would mean one family member wants you to honor it and another doesn't. Not a good scene!

Since we're not lawyers and cannot interpret legal documents (no matter who shows you what!), I'd say in all three cases, begin resus, get the pt. into the ambulance and get his doctor on the line for permission to call it or continue.

If your ambulance service has records on individual pts with DNRs (like "expected deaths") then you have to follow the protocol for it, regardless of the wishes of the relatives.

And how do you know who's really in charge? Again, they'd have to prove power of attorney and you can't interpret that document either, and don't have the time to mess around.

The scenarios, as you describe them, are asking you to play Tug of War!

 

[JPINFV]

"So if I have family members on scene asking me to resuscitate, I've got 3 reasons alone why I should start resuscitation and contact a base hospital"

Youre saying that if the family members want resuscitation and there is a DNR order that is there and valid you are going to attempt to resuscitate?

For the vast majority of protocols sets I've seen? Yes.

In EM/EMS position where we are operating off of limited information and without being bound by protocols, I would still argue that the proper course would be to resuscitate. To reiterate what I said earlier, I have no clue what the patient said before arrest. To choose to not resuscitate is final and can't be undone. On the other hand, medical care and resuscitation can always be removed later.

 

[Smellypaddler]

My post about suing was in regards to the law here.

Unless a family member has a signed medical power of attorney then they can't make a decision regarding the health care of their other family members.

So regardless of what they say, scream or do it is the right of the patient to not have resuscitation started.

 

[JPINFV]

Since you can't interpret legal documents, then how do you know who has power of attorney?

Similarly, how do psych holds work, since those are legal documents that you can't interpret?

 

[JPINFV]

My post about suing was in regards to the law here.

Unless a family member has a signed medical power of attorney then they can't make a decision regarding the health care of their other family members.

So regardless of what they say, scream or do it is the right of the patient to not have resuscitation started.

So then it stands to reason that if a patient becomes incapacitated due to a medical condition (say, intubated, sedated, and being treated in the ICU), the physician makes all medical decisions without input from the immediate family until the court appoints a medical power of attorney?

 

[Underoath87]

I understand this is theoretical but how are you going to know there is a DNR order (signed) unless the family gives it to you? That would mean one family member wants you to honor it and another doesn't. Not a good scene!

Exactly. And chances are, the person handing you the DNR is also going to be the power of attorney or the next best thing on scene, so this is pretty much a non-issue.
In the real world, there would be little chance of conflict here unless you found the DNR in the PT's pocket or something.