DNR and assisted ventilations.

[Clipper1]

Nobody is talking about with holding treatment, only doing what the patient wants and keeping them comfortable. I said to advocate for the pt, no kill them. Why do you not pay attention?

Believe me. I know all about hospice, unfortunately . More than most.
Believe it or not, it does mean the end is near, the patient and the doctor have usually decided the patient has less than 6bmonths.

Reread some of the other posts. There are many more posts here and not just yours. I also did not quote yours so what are you doing with this personal attack.

You might know about your own personal experience for a hospice pt but that is not how all hospice pt are managed. Did you know there is even ltc housing for hospice patients who might live up to a year or more? Those of us who do work with hospice want both quality and comfort. Every patient is different. If you are in Washington I could have taken care of someone you know especially if it involed a child. If you were not happy wiyh the care you should have had the opportunity to talk to the RNs and doctor.

 

[Mariemt]

Reread some of the other posts. There are many more posts here and not just yours. I also did not quote yours so what are you doing with this personal attack.

You might know about your own personal experience for a hospice pt but that is not how all hospice pt are managed. Did you know there is even ltc housing for hospice patients who might live up to a year or more? Those of us who do work with hospice want both quality and comfort. Every patient is different. If you are in Washington I could have taken care of someone you know especially if it involed a child. If you were not happy wiyh the care you should have had the opportunity to talk to the RNs and doctor.

I was the only one who said advocate, when you used that in the sense you did, I knew that part was directed back at me. And if you think that was a personal attack I'd hate to see what a real one would do to you. I am not going to personally attack anyone. Good grief
Yes I know there are housing for hospice
Where did I say at all I was unhappy with the hospice services? They were fantastic. It was unfortunate like many others I had to lose someone so close to me.


If the patient that this thread is about had more than a year, from the condition listed, I'm thinking him or his wife would have driven him to the doctor. A nurse wouldn't have had to call.
That's why I believe he is coning to the end of life.

Most, MOST of the time, hospice is for people who have less than six months, who have excepted they will die and do not plan to per sue heroic Measures etc etc. They do standard treatments for comfort. However no chemo, radiations etc etc. They do still take antibiotics as needed high blood pressure meds, typical meds that improve the quality of their life.

Some people have gone off hospice care. Later to go back on. They had decided to fight their disease with new treatments, or even their outlook was better and they were defying odds.
Your state is obviously different.

But I never once said I was unhappy with the care. Don't put words in my mouth

 

[JPINFV]

Having PNA which is not treated is not comfort. Many patients in hospice are not always "near death".

To be fair, they are supposed to be within 6 months of death to qualify for Medicare hospice specifically.

http://www.medicare.gov/Pubs/pdf/02154.pdf Page 4.

 

[savemachine]

Dnr

I'm sure the answer is on here somewhere, but I searched and couldn't find it. So:

You've been called to the scene for 70yo male with irreversible kidney failure, due to the onset of pneumonia with associated DIB. Hospice nurse is on scene and is the one who called. Wife brings you a DNR for the patient. Pt is breathing 8-10 times a min with rales and wheezing bilaterally.

Am I correct to assume that as long at this pt. is breathing on their own we can provide respiratory assistance with a BVM, but if they become apnic (but not pulseless) we must stop ventilations? Or do we continue ventilations until the patient become pulseless as well? :huh:

Thanks.

DNR is do not resuscitate. Looks like in this situation it is just treatment, not resuscitation.

 

[Clipper1]

To be fair, they are supposed to be within 6 months of death to qualify for Medicare hospice specifically.

http://www.medicare.gov/Pubs/pdf/02154.pdf Page 4.

Not every patient is coveted by Medicare. There are also private foundations which support Hospice services.

 

[Einstein]

Dnr

wow
im amazed

the answer to the question is simple

dnr means "do not resuscitate"....not "do not withhold care"

if theyre pulsless aned apneic then can withhold

if not then you MUST assist their ventilations

if they have advanced directive, stating no ventilation thats different

but if not you will be killoing the patient

nurses call for medics with hospice patients with sob and dnrs because theyre not in arrest. they may do well for years, and have bouts of sob.....that doesnt mean its your day to kill them

 

[Aidey]

wow
im amazed

the answer to the question is simple

dnr means "do not resuscitate"....not "do not withhold care"

if theyre pulsless aned apneic then can withhold

if not then you MUST assist their ventilations

if they have advanced directive, stating no ventilation thats different

but if not you will be killoing the patient

nurses call for medics with hospice patients with sob and dnrs because theyre not in arrest. they may do well for years, and have bouts of sob.....that doesnt mean its your day to kill them

Not a DNRs are that simple. Many states use POLST forms and depending on what options are selected on the POLST form assisted ventilations may not be ok, even in a patient that still has a pulse.

 

[Einstein]

dnr

i love the comment about beating people on back boards......


i say hell-to-the-yeah!!!

rotflol

 

[JPINFV]

wow
im amazed

the answer to the question is simple

dnr means "do not resuscitate"....not "do not withhold care"

if theyre pulsless aned apneic then can withhold

if not then you MUST assist their ventilations

if they have advanced directive, stating no ventilation thats different

but if not you will be killoing the patient

nurses call for medics with hospice patients with sob and dnrs because theyre not in arrest. they may do well for years, and have bouts of sob.....that doesnt mean its your day to kill them

Except... it doesn't work that way. When the patient declines via advanced directive mechanical ventilation, then they decline mechanical ventilation. It's not a "Well, we can intubate them, and throw them on a vent as long as they're the ones triggering the vent."

 

[Einstein]

Hmmmm

If they are dn"R" then it's dn"R"

We can debate foreger If they had a poorly thought out advanced directive etc or none, etc etc etc

But the question was, do you ASSIST a pt w/sob that has DNR?

In most states (at least mine)(lol) you MUST (as in duty to act) (and maybe even under implied consent) can't do nothing wen yur called to assist and the pt ain't dead

Advanced directive etc is a whole separate debate

 

[Aidey]

It isn't a different debate. My state uses the POLST form. If they are having SOB and have selected palliative care I am not allowed to intubate or assist their ventilations in any way, including CPAP. I can give them oxygen and inhaled medications. But no ventilatory assistance, period.

People have a right to refuse certain types of care, and a right to die. DNRs/advanced directives/POLST forms are ways of revoking consent to certain procedures. Your "duty to act" does not over rule those.

 

[TransportJockey]

Here in nm an EMS DNR does not allow anything but palliative care. No CPR, assisted ventilations, advanced airways, electricity, etc.

 

[Einstein]

dnr

HMMM

I should look up or ask you to remind me what POLSTB means in your state. ...

I personally dont know what state yur in, but

We were talking about DNR. not POLST. if your state uses polst, and that polst allows for no cpr/bvm but everything else, then thats a DNR.

dnr means do not resuscitate. assisting breathing is palliative and mandatory UNLESS THEY STATE otherwise. assisting ventilation is ASSISTING not resusitating. thats why there are spelled differently. ventilating someone where there is no natural ventilation is resusitating.

 

[chaz90]

HMMM

I should look up or ask you to remind me what POLSTB means in your state. ...

I personally dont know what state yur in, but

We were talking about DNR. not POLST. if your state uses polst, and that polst allows for no cpr/bvm but everything else, then thats a DNR.

dnr means do not resuscitate. assisting breathing is palliative and mandatory UNLESS THEY STATE otherwise. assisting ventilation is ASSISTING not resusitating. thats why there are spelled differently. ventilating someone where there is no natural ventilation is resusitating.

You're vastly over simplifying this issue. Under some circumstances and DNRs, ventilations are considered invasive life support and are not to be provided to patients with a DNR. As we've told you, this isn't universal.

 

[Akulahawk]

HMMM

I should look up or ask you to remind me what POLSTB means in your state. ...

I personally dont know what state yur in, but

We were talking about DNR. not POLST. if your state uses polst, and that polst allows for no cpr/bvm but everything else, then thats a DNR.

dnr means do not resuscitate. assisting breathing is palliative and mandatory UNLESS THEY STATE otherwise. assisting ventilation is ASSISTING not resusitating. thats why there are spelled differently. ventilating someone where there is no natural ventilation is resusitating.

A DNR in California means the following:

• No chest compressions
• No assisted ventilation (No BVM, no vent, CPAP is OK)
• No endotracheal intubation
• No defibrillation
• No cardiotonic drugs

As long as what you do does NOT fit the above things, then you're good to go. The patient does NOT have to be in an arrest situation before the DNR applies. Assisting ventilation IS resuscitation because you're forcing the person to breathe mechanically. CPAP just supplies pressurized air, the patient does the work of breathing. All the work. The patient can get antibiotics, tube feeding, IV nutrition, IV fluids (as long as it's not for resuscitation purposes), and so on.


A POLST form is much more specific about the allowed treatment. If the patient wants CPR done, they also request full measures as well, but they can select no tube feeding.


The other difference between the two forms is that a Prehospital DNR is only valid outside the hospital, even though hospitals are encouraged to honor it. The POLST is valid everywhere and follows the patient.

Other states may have different definitions from California, know your state's rules and follow those.

 

[Einstein]

I appreciate the banter, as i usually dont blog or posty or whatever im doing

i shud do this more often. i just learned about NM protocol.

But guys, im not over simplifying: Think about what youre saying.....So youre called to a street outside in an industrial area to find a 62 year old healthy, athletic looking Fire dept captain off duty whos gotm a bit of JVD, 02sat is poor and dropping, what appear to be rales....could be rales andf wheezes....has every sign of respiratory distress, and has a DNR bracelet and no other Hx Meds or NKDA.

Youre not going to do anything?

Seriously: Did this guy have toxic inhalation? CHF? Anneurism? Preexisting cardiac issues? asthma? exacerbation of some gasteroenterologic issue or rupture? PE?

Maybe the dnr bracelet worn "just in case" because after 28 years in Los Angeles Fire this guy's seen everything and doesnt want to be left vegetative after catastrophic trauma resulting in resuscitated arrest?

YOU DONT KNOW.

Secenario 2
Old person with cancer end stage, with COPD, asthma, siezure disorder, lupus and hx of dialysis who in 9 months WILL want to go naturally, BUT TODAY is only having sever asthma attack?

DNR and POLST and advanced directive should be what they are; highly specific. What does the state of NM expect you to do under the above situations? Just let the guy gasp and die on the sidewalk b/c he has a DNR. Remeber the debate was CAN YOU ASSIST VENTILLATIONS on a DNR. and the answer is in the name: do nor resuscitate. that means DO NOT bring back from dead.

However, OBVIOUSLY if a polst says no vent assist on a dnr.....then your choices are simple: either dont assist, break the law and assist, or become a EMS policy maker and change ridiculous law that says NO ASSIST for the guys in the above scenario

 

[TransportJockey]

I appreciate the banter, as i usually dont blog or posty or whatever im doing

i shud do this more often. i just learned about NM protocol.

But guys, im not over simplifying: Think about what youre saying.....So youre called to a street outside in an industrial area to find a 62 year old healthy, athletic looking Fire dept captain off duty whos gotm a bit of JVD, 02sat is poor and dropping, what appear to be rales....could be rales andf wheezes....has every sign of respiratory distress, and has a DNR bracelet and no other Hx Meds or NKDA.

Youre not going to do anything?

Seriously: Did this guy have toxic inhalation? CHF? Anneurism? Preexisting cardiac issues? asthma? exacerbation of some gasteroenterologic issue or rupture? PE?

Maybe the dnr bracelet worn "just in case" because after 28 years in Los Angeles Fire this guy's seen everything and doesnt want to be left vegetative after catastrophic trauma resulting in resuscitated arrest?

YOU DONT KNOW.

Secenario 2
Old person with cancer end stage, with COPD, asthma, siezure disorder, lupus and hx of dialysis who in 9 months WILL want to go naturally, BUT TODAY is only having sever asthma attack?

DNR and POLST and advanced directive should be what they are; highly specific. What does the state of NM expect you to do under the above situations? Just let the guy gasp and die on the sidewalk b/c he has a DNR. Remeber the debate was CAN YOU ASSIST VENTILLATIONS on a DNR. and the answer is in the name: do nor resuscitate. that means DO NOT bring back from dead.

However, OBVIOUSLY if a polst says no vent assist on a dnr.....then your choices are simple: either dont assist, break the law and assist, or become a EMS policy maker and change ridiculous law that says NO ASSIST for the guys in the above scenario

I'm curious about what part of 'no artificial ventilations' is not clear?
Patient one would get CPAP and the full press short of intubation and ventilations.
Patient two would get meds (IM Epi is allowable as its a different route and concentration than what it used for an arrest) and full protocol including CPAP. Up to and excluding intubation and ventilations.

EMS DNRs are revocable by the patient or their designee, however. Although if I had a dnr and my family revoked it, they will be meeting me in hell, because I'll kill them where they stand.

 

[JPINFV]

I appreciate the banter, as i usually dont blog or posty or whatever im doing

i shud do this more often. i just learned about NM protocol.

But guys, im not over simplifying: Think about what youre saying.....So youre called to a street outside in an industrial area to find a 62 year old healthy, athletic looking Fire dept captain off duty whos gotm a bit of JVD, 02sat is poor and dropping, what appear to be rales....could be rales andf wheezes....has every sign of respiratory distress, and has a DNR bracelet and no other Hx Meds or NKDA.

Youre not going to do anything?

If only there was a way to treat that that didn't involve intubation. Oh, wait...

Maybe the dnr bracelet worn "just in case" because after 28 years in Los Angeles Fire this guy's seen everything and doesnt want to be left vegetative after catastrophic trauma resulting in resuscitated arrest?

YOU DONT KNOW.

So, because we're not BFFs with the patient, we just ignore the DNR bracelet because, heck, maybe it's a fashion accessory?

 

[Wheel]

However, OBVIOUSLY if a polst says no vent assist on a dnr.....then your choices are simple: either dont assist, break the law and assist, or become a EMS policy maker and change ridiculous law that says NO ASSIST for the guys in the above scenario

It's a "ridiculous law" that says a patient can put that they want no artificial ventilations in a POLST? How come you get to make their care decisions for them? As you said you don't know their reasons for having that.

Plus, no EMS policy maker is going to make care decisions for any patient. They have a right to refuse any treatment at any time.

 

[Einstein]

no
its quite simple
do not resuscitate means if im dead (pulseless apenic) do not vent and no cpr or drugs

advance directive and polst covers no cpr or drugs, but if i just need vent, then ok. or cpr and vent ok, but no drugs. etc...

I dont understand why you make the leaps of logic that you do, no offense. I mean, no cheeseburger doesnt mean no hamburger. it means no hamburger with cheese.

so in my scenario, why would you do anything if he has a DNR? some of you said youd do everything but assist vent or et? some of you said nothing because of the dnr. see the problem here???

we dont have the choice. if hes dead with dnr we cant bring him back. Period. if hes not dead then we obligated to do all we can UNLESS HE HAS SPECIFIC INSTRUCTIONS ON HIS POLST what to do and what not to do.

period. end of concept.

its no accident there is such a thing as "DNR" and another separate words called "advance directive"? cow is cow, not cow might mean dog. different words mean differnt things. thats why we have an alphabet. so do not dnr patients with asthma get treatment while those in arrest dont.

can anyone give me a logical explanation why youd take someone whos not dead and apply a DO NOT RESUSCITATE to them. they dont need resuscitation.......theyre alive.


if in your state there is only a polst and that covers dnr, or other specific things, then you must follow that. but if your state has a polst, and on it theres a box labeled DNR as one of many boxes and that is the only box the patient checked, then it must be followed.

heres the scary part: this is just my opinion. im not a lawyer. im not a beurocrat. im a retired firefighter paramedic who actually taught at a major university. and thats what we taught!!! (cuz it makes sense...or at least it did a few years ago)