DNR and assisted ventilations.

[JPINFV]

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)

Major university? So... UCLA? You do realize that UCLA's paramedic school doesn't count as being UCLA, right?

 

[DesertMedic66]

This may help clear up some confusion for California (it has kind of already been posted)

EMSA/CMA APPROVED PREHOSPITAL DNR FORM
1. Under the EMSA/CMA approved Prehospital DNR Form, do not resuscitate (DNR) means no chest compressions, defibrillation, endotracheal intubation, assisted ventilation, or cardiotonic drugs.
2. The patient should receive all other care not identified above for all other medical conditions according to local protocols.

EMSA APPROVED POLST FORM
EMS personnel who encounter the EMSA approved POLST form in the field should be aware of the different levels of care in Sections A and B of the form (Section C does NOT apply to EMS personnel).
Section A applies only to individuals who do NOT have a pulse and are NOT breathing upon arrival of EMS personnel.
If an individual has checked “Attempt Resuscitation/CPR”, then EMS personnel should treat the individual to the fullest extent possible according to local protocols regardless of what may be checked in Section B. For this individual this form as filled out does NOT constitute a DNR.
If the individual has checked “Do Not Attempt Resuscitation/DNR”, then no attempts should be made to resuscitate the individual and the EMS personnel should follow their local policies, procedures and protocols for declaration of death.
Section B applies only to individuals who have checked “Do Not Attempt Resuscitation/DNR” in Section A AND who have a pulse and/or are breathing upon the arrival of EMS personnel.
If an individual has checked “Comfort Measures Only” the following care may be provided:
The patient should receive full palliative treatment for pain, dyspnea, major hemorrhage, or other medical conditions (includes medication by any route) according to local protocols.
Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped and the patient is unconscious, ventilation should not be assisted.
If an individual has checked “Limited Additional Interventions” the following care may be provided (in addition to the care outlined above):
Administration of IV fluids.
May use non-invasive positive airway pressure to include: continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations according to local protocols. This does NOT include intubation.

Source: http://www.emsa.ca.gov/pubs/default.asp#EMSA111
Section EMSA #111

 

[Akulahawk]

While you're referring to NM, I'm going to answer from California's perspective. My answers to you will be inline and in red.

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? Actually, I'm going to do what my training and assessment tell me, with the DNR bracelet in mind. He's likely going to get oxygen, and if he's wheezing and I think it's responsive to albuterol, he'll get that. If he's in acute heart failure and needs a dopamine or epi drip, well, that's off limits. They're cardiotonic drugs.

Seriously: Did this guy have toxic inhalation? CHF? Anneurism? Preexisting cardiac issues? asthma? exacerbation of some gasteroenterologic issue or rupture? PE? The DNR prevents me from providing ONLY some very specific things. It does NOT prevent me from providing care. If he's conscious, I can get consent to treat. If it's a toxic inhalation, and I have a reversal agent on board, the agent might be OK to use.

Maybe the dnr bracelet worn "just in case" because after 28 years in Los Angeles Fire this guy's seen everything and doesn't want to be left vegetative after catastrophic trauma resulting in resuscitated arrest?

YOU DONT KNOW. He is allowed to verbally rescind the DNR, and I do know that he made the decision with his physician. Until he does rescind the DNR, I'm bound by the rules of the system I work within to honor the DNR.

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? Then today he gets albuterol and maybe Epi. Intent is relief from symptoms, not resuscitation. If he has a POLST that directs otherwise, then I must follow that directive.

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. Resuscitation also can mean prevent from becoming 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 Or you can understand that a DNR / POLST was designed to convey the patient's wishes so that you don't provide care that is contrary to their wishes. It's the patient's right to refuse, and put it in writing so that you know what has been decided upon between the patient and the patient's physician. DNR and POLST are directives to YOU.

Good discussion, but unfortunately many of us have a better understanding of the complexities of DNR/POLST than you do. There are aspects about those things that we don't like because we're normally quite DRIVEN to try to bring back the dying. We must think about what we do, and not emote our way through it.

 

[Akulahawk]

More comments in red for you.

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

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... An Advanced Directive may not hold legal weight in the prehospital arena. Where I used to work, only 2 documents meant anything to me: DNR or POLST. Both had to be properly signed.

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??? It also means no cardiotonic drugs. That means no dopamine, no epi drips... even if they're alive because that's resuscitation if they're used to support life.

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. Concept of DNR you have missed. DNR patient with asthma gets symptom relief using albuterol and other drugs to relieve the symptoms. Patient wheezing because they're in heart failure doesn't get drugs to improve cardiac function.

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. POLST forms require all sections be filled out. If only the No CPR check box is selected, and it's otherwise properly signed, I will honor it as a DNR form - with all the restrictions of DNR - even if the patient is alive. My region may consider that form invalid for patient care and require full code/care because all portions of the form haven't been visited. If that's the case, then I'll default to Full Code.

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) You're not a lawyer, and neither am I. It's obvious to me that you don't have as concrete an understanding of the DNR /POLST topic as you should to teach this to other people.

It doesn't matter to me whether you are a retired FF/P that taught at a major university or not. It's obvious that you don't understand this topic sufficiently well.

 

[Rialaigh]

I think most people are way overshooting here.

Any scene I pull up that involves any questionable treatment of a DNR patient will involve the following.

Assuming the patient is conscious, they will get whatever treatment THEY WANT. I will not in any way shape or form try to force or place treatment on them that they do not specifically want. Treatment will be offered, they will decide, there will be no calling medical control or a supervisor or whoever else to try and convince them of the treatment. By all means if your a DNR and you don't want to wear a nasal cannula, power to you.

If your having trouble making decisions or your somewhat incapable of making decisions and your spouse is on scene. It is very likely that my treatment will almost mimic whatever the spouse wants done (as long as the spouse verbalizes that he/she is acting in the interest of the DNR party).


Point being most DNR decisions are not about what your legally ABLE to do, it is about being comfortable respecting a decision from either the patient or a spouse or medical power of attorney making decisions on behalf of the patient.


If someone is having a ton of trouble breathing, is semi conscious and unable to make a decision for themselves, and presents with a spouse who has a DNR for them and the spouse says they would not have wanted any O2 or breathing assistance, I have to make a decision based on what I think the patient wants, and given the information I have there is nothing that leads me to believe the patient wants to be bagged, only information leading me to believe the patient would NOT want to be bagged, you have to be comfortable making that distinction and that decision.

 

[Einstein]

Ok then
Tell me where I don't understand

If the patient is alive what does a DNR have to do with this?

You tell me I clearly don't understand, then you articulate........

Why would a do not RESUSCITATE be relavent to a LIVE person?

 

[DesertMedic66]

Ok then
Tell me where I don't understand

If the patient is alive what does a DNR have to do with this?

You tell me I clearly don't understand, then you articulate........

Why would a do not RESUSCITATE be relavent to a LIVE person?

If that live person stops breathing or looses a pulse.

 

[Einstein]

And btw
This is my first time or two posting.....don't get nasty and say I clearly don't know wat I'm saying......

Re my experience
First of all I was being humble

Secondly
I've met many paramedics that I think were better than I and they were raised and schooled in Podunk nowhere. So don't be so quick to judge

Lastly It would be just as easy for me to say experience has PROVEN to be clinically sound in a university ER evironmemt sometimes surrounded by (and watching with great curiosity) leading cardiologists having lively debates, etc

I didn't get signed off by some preceptor (thank you I'm done now like so many barely competent medics across America....maybe you)

I was greatfull and honored and humbled and fascinated by lecturers and leaders in their field on a regular basis. If you were at all perceptive you'd have read what I said and seen I'm still humbled and amazed at the power we are given

But enough of that......
Where's your answer: WHY RESUSCITATION ORDER BE RELAVENT TO A LIVE PERSON?

You also never answered the question I posed about the hospice patient 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......

Wats the answer to that? You withhold tx?

 

[Aidey]

Are you being deliberately obtuse? I think we have all made ourselves incredibly clear on this issue. The pt would be treated but not resuscitated. If they stop breathing, assisting their ventilations IS resuscitation, unless otherwise specified in the DNR paperwork. What is so hard about this for you to understand?

Also, to enroll in most hospice programs the pt has to have a life expectancy of 6 months or less.

 

[VFlutter]

Major university? So... UCLA? You do realize that UCLA's paramedic school doesn't count as being UCLA, right?

My EMT certificate, from a university affiliated program, looks just like my college Diploma h34r:

And btw
This is my first time or two posting.....don't get nasty and say I clearly don't know wat I'm saying......

Welcome to the Thunderdome, I mean EMTlife.

Re my experience
First of all I was being humble

I am sure you were.

Lastly It would be just as easy for me to say experience has PROVEN to be clinically sound in a university ER evironmemt sometimes surrounded by (and watching with great curiosity) leading cardiologists having lively debates, etc

You keep mentioning "University" like it is supposed to impress us. How does being surround by and watching "leading" Doctors give you any credibility?

My college was affiliated with one of the best Medical schools in the country. I did all my clinicals at one of the best hospitals in the country alongside prestigious medical professionals. Can I have a cookie? This does not add anything to my argument.

I didn't get signed off by some preceptor (thank you I'm done now like so many barely competent medics across America....maybe you)

Ok? Almost every Medical profession has some type of preceptorship for new graduates. Were you just born a competent medic?

You also never answered the question I posed about the hospice patient 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......

Wats the answer to that? You withhold tx?

If this patient is a hospice patient then yes you withhold treatment. Hospice is comfort measures only and absolutely no life prolonging treatments.

Not all patients with a DNR are on hospice. All patients on hospice will have a DNR.

DNR does not mean Do Not Treat. Of course you would give nebs, 02, etc.

 

[Einstein]

wow
A: not being obtuse. read every entry. Ive said someone breathing and circling the drain gets treatment despite DNR, while OTHERS have said breathing with DNR aint allowed. THATS BEEN THE DEBATE.

But moving on,
I mean you've got to be kidding me:
you just wrote, "If they stop breathing, assisting their ventilations IS resuscitation"...........

wow
Thats heavy.
NO!!! Assisting ventilations means ASSISTING someone. You know, like PEEP. As in CPAP being a form of assisted ventilation. People who've stopped breathing are apneic and you arent assisting them. YOU ARE ALONE VENTILATING them. When you are BAGGING a patient in vfib you arent assisting ventilation.

re:
Also, to enroll in most hospice programs the pt has to have a life expectancy of 6 months or less.

.....I either did not know or forgot that. Thank you

 

[Aidey]

wow
A: not being obtuse. read every entry. Ive said someone breathing and circling the drain gets treatment despite DNR, while OTHERS have said breathing with DNR aint allowed. THATS BEEN THE DEBATE.

But moving on,
I mean you've got to be kidding me:
you just wrote, "If they stop breathing, assisting their ventilations IS resuscitation"...........

wow
Thats heavy.
NO!!! Assisting ventilations means ASSISTING someone. You know, like PEEP. As in CPAP being a form of assisted ventilation. People who've stopped breathing are apneic and you arent assisting them. YOU ARE ALONE VENTILATING them. When you are BAGGING a patient in vfib you arent assisting ventilation.

re:
Also, to enroll in most hospice programs the pt has to have a life expectancy of 6 months or less.

.....I either did not know or forgot that. Thank you

Now you're just being pedantic.

People have made it incredibly clear that what treatment is and isn't allowed when a patient has a DNR varies by location and the exact wording on the DNR. You will not get a consensus on this because of those variations.

 

[Handsome Robb]

wow
A: not being obtuse. read every entry. Ive said someone breathing and circling the drain gets treatment despite DNR, while OTHERS have said breathing with DNR aint allowed. THATS BEEN THE DEBATE.

But moving on,
I mean you've got to be kidding me:
you just wrote, "If they stop breathing, assisting their ventilations IS resuscitation"...........

wow
Thats heavy.
NO!!! Assisting ventilations means ASSISTING someone. You know, like PEEP. As in CPAP being a form of assisted ventilation. People who've stopped breathing are apneic and you arent assisting them. YOU ARE ALONE VENTILATING them. When you are BAGGING a patient in vfib you arent assisting ventilation.

re:
Also, to enroll in most hospice programs the pt has to have a life expectancy of 6 months or less.

.....I either did not know or forgot that. Thank you

You're obviously not nearly as competent as you think.

CPAP is not assisted ventilations.

Assisted ventilations are a temporizing measure until the patient can be intubated, thus resuscitation. You lose, go straight to jail, do not pass go, do not collect 200 dollars.

I graduated from a program affiliated with a University and its med school...can I have a cookie too? Or at least half of Chase's?

 

[Einstein]

regarding whoever said i was being pedantic

i saw that word on family guy once....what an episode!!! HI-LARIOUS

I dont know what it means
but i do know this
this whole debate has been about do not RE\SUSCITATE someone who is still breating. nothing more nothing less.

but if where this whole debate has lead is tantamount to the difference between withholding care on someone due to

OK..I had to do it. I looked up PEDANTIC

(a minute goes by)
wow
im gonna just sign off now.
by my last posting i think im proved that resuscitate menas BRING BACK not assist so they dont crash,

i dont know what to say..............

if anyone out there thinks that witholding treatment on an asthmatic patient with a dnr is mincing words or splitting hairs or being pedantic, then

A)
let me know what county you work in an ill make sure never to allow myself or loved ones to drive thru there,

B)
Id think long and hard about how many people I withheld from erroneously

AND
C)
i think its time for you to say, like I have many times here, "hmmmm.....thanks, i did not know that."

signing off and thanks for the banter.

 

[Handsome Robb]

A)
let me know what county you work in an ill make sure never to allow myself or loved ones to drive thru there,.

I was just gonna ask you this. Post it up so it's public knowledge because you are dangerous.

I'd venture to say, based on your grammar, USE OF CAPITAL LETTERS, and lack of a intelligent argument you're still a probie. Or maybe even a white shirt!

 

[chaz90]

Well, this has been entertaining. Apparently some concepts I thought were easy to understand just aren't by some people. Goodbye freepratique. I hope (though I have my doubts) that you were able to learn something.

 

[VFlutter]

A)
let me know what county you work in an ill make sure never to allow myself or loved ones to drive thru there,

Ah how childish. I am glad you are retired, probably before I was even born, and no longer adding to the ignorance so rampant in EMS.

You should hope you or your loved ones are lucky enough to be treated by one of our awesome forum members who are undoubtedly some of the best in EMS.

And I like to think that I have allowed many patients their right to die with dignity on their own terms. That is something I would not dare take away.

 

[DesertMedic66]

regarding whoever said i was being pedantic

i saw that word on family guy once....what an episode!!! HI-LARIOUS

I dont know what it means
but i do know this
this whole debate has been about do not RE\SUSCITATE someone who is still breating. nothing more nothing less.

but if where this whole debate has lead is tantamount to the difference between withholding care on someone due to

OK..I had to do it. I looked up PEDANTIC

(a minute goes by)
wow
im gonna just sign off now.
by my last posting i think im proved that resuscitate menas BRING BACK not assist so they dont crash,

i dont know what to say..............

if anyone out there thinks that witholding treatment on an asthmatic patient with a dnr is mincing words or splitting hairs or being pedantic, then

A)
let me know what county you work in an ill make sure never to allow myself or loved ones to drive thru there,

B)
Id think long and hard about how many people I withheld from erroneously

AND
C)
i think its time for you to say, like I have many times here, "hmmmm.....thanks, i did not know that."

signing off and thanks for the banter.

Well I work in California (where you said you used to work).... I also quoted CA state DNR/POLST policy which answers most if not all your questions.

 

[DesertMedic66]

Ah how childish. I am glad you are retired, probably before I was even born, and no longer adding to the ignorance so rampant in EMS.

You should hope you or your loved ones are lucky enough to be treated by one of our awesome forum members who are undoubtedly some of the best in EMS.

And I like to think that I have allowed many patients their right to die with dignity on their own terms. That is something I would not dare take away.

I feel like being a little childish hahaha

 

[Einstein]

RE
And I like to think that I have allowed many patients their right to die with dignity on their own terms. That is something I would not dare take away.

I would like to think that too