DNR and assisted ventilations.

[Akulahawk]

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 relevant to a LIVE person?

Resuscitate means to bring back. In this case, to bring back from death or impending death. So, a DNR patient who is in septic shock, but still alive, gets antibiotics and perhaps fluids, but not pressors to maintain BP. Why? Because pressors are cardiotonic. "Fluids" can be given PO or by IV. When the patient is circling the drain, and they've chosen to not be thrown a lifeline, it's their right to die.

Here's one for you: If your patient is clearly altered, has a heart rate of 22 and a BP that's barely palpable and is breathing 4 times a minute, are you going to start CPR? Are you going to hang dopamine or epinephrine, or put the patient on a pacer?This patient does have a valid DNR. This patient clearly isn't dead yet, so by your criteria, the patient is to be treated as full code...

 

[Akulahawk]

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.

We're lucky enough to actually have some of the best here on this forum.

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.

I also used to work in California. DesertEMT did post California's DNR/POLST policy. It's pretty clear what California does and does not permit.

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

I know that I took many people home to die with dignity, surrounded by loved ones. Many of those people would have been Code 3 runs to the ED because they were so unstable, or I would have refused transport from the acute care hospital were it not for the DNR/POLST. Instead, I made sure they got home so that they could make their way to the ECU with as little drama as possible.

 

[Akulahawk]

I should also mention that most if not all of the forum members chiming in this thread are quite willing and able to go as aggressive as necessary (within our scope of practice) in providing care for our patients. I'm probably as guilty as pretty much everyone here in going all out in attempting to resuscitate patients that really should have been left alone, because we were required to do it.

 

[VFlutter]

Our hospital has a fantastic Palliative care team that approaches families with end of life decisions. They are great at helping families with DNR/Hospice options. It has really helped reduce the number of futile resusiations and ICU admissions. Unfortunately EMS does not have the luxury.

Another side note: Let families witness and be a part of codes. Numerous studies have shown it is better for everyone involved. Many people do not realize how violent CPR is or the extent of what we do. I have had families stop a code after I started CPR because they saw, and heard, how intense my compressions are.

 

[Akulahawk]

Our hospital has a fantastic Palliative care team that approaches families with end of life decisions. They are great at helping families with DNR/Hospice options. It has really helped reduce the number of futile resusiations and ICU admissions. Unfortunately EMS does not have the luxury.

Another side note: Let families witness and be a part of codes. Numerous studies have shown it is better for everyone involved. Many people do not realize how violent CPR is or the extent of what we do. I have had families stop a code after I started CPR because they saw, and heard, how intense my compressions are.

Not only that, but if you're able to spare someone to provide care for the family and keep the family informed as the code progresses, the family has an even better understanding what happened and will more readily accept the termination of the code and the death of their loved one. It may also keep the family from suing because something wasn't done during the code. They may still sue because they may think something went wrong that caused the code... but not because of the code itself.

 

[Rialaigh]

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?

Your missing the point of what I am saying. If the patient has a DNR it almost always alters how THEY want to be treated when they are alive. Most elderly patients with DNR's that I have encountered do not want to be placed on Cpap, don't want a breathing treatment, don't want nitro paste, etc..etc...etc..


No a DNR does not mean do not treat, however for me it means I am extra careful to completely abide by the patients wishes regarding what treatment they do want, and often times that treatment is pretty close to nothing. I have no problem not putting oxygen on someone satting 70% because they are a DNR AND they have said they do not want oxygen, if they go unresponsive afterwards I am not going to put oxygen on them then because we are "supposed to treat", the patient made it clear their wishes and their wishes still stand after they go unresponsive.

When you encounter someone with a DNR that is decently responsive (Able to make a decision) you should never be asking yourself what your obligated to do or what the best treatment is for the patient, you should be asking yourself (and the patient) what does this patient want, how can I treat this patient the way that they want.

 

[Clipper1]

I think some of you are stereotyping the DNR and Hospice patient. Not all are elderly terminal patients. Yes, they may be terminal but sometimes you do get the 30 year old woman with breast cancer who is still fighting to spend as much time at home with her kids during her last months with whatever quality of life a hospice program can provide. To have it cut short by something which is reversible like maybe a pneumonia would be a tragedy.

For hospice patients, listen to the nurse and the family if they are present. Read the hospice instructions which also will usually include what treatment is acceptable for conditions deemed as reversible. Don't jump to conclusions right away about what this person wants before you get the facts. If anyone has ever been to a cancer survivor walk or some type of event you might be surprised to meet a few who were in hospice at one time.

 

[Akulahawk]

My responses in red, inline to make it easier to respond to your points.

I think some of you are stereotyping the DNR and Hospice patient. Not all are elderly terminal patients. I've seen enough to know that. Yes, they may be terminal but sometimes you do get the 30 year old woman with breast cancer who is still fighting to spend as much time at home with her kids during her last months with whatever quality of life a hospice program can provide. To have it cut short by something which is reversible like maybe a pneumonia would be a tragedy. Yes, which is why they can still get antibiotics. Cure that infection and their comfort level goes way up. That patient isn't going to get pressors to maintain BP unless the DNR/POLST/Hospice program is terminated or the paperwork clearly allows use of pressors.

For hospice patients, listen to the nurse and the family if they are present. Actually, I won't. Not for care directions. I want to see the documents FIRST. Read the hospice instructions which also will usually include what treatment is acceptable for conditions deemed as reversible. It will also tell me who I can legally listen to for care instructions. Don't jump to conclusions right away about what this person wants before you get the facts. I don't. That's because I read the documentation and GET the facts. If anyone has ever been to a cancer survivor walk or some type of event you might be surprised to meet a few who were in hospice at one time.

 

[Einstein]

re:
Here's one for you: If your patient is clearly altered, has a heart rate of 22 and a BP that's barely palpable and is breathing 4 times a minute, are you going to start CPR? Are you going to hang dopamine or epinephrine, or put the patient on a pacer?This patient does have a valid DNR. This patient clearly isn't dead yet, so by your criteria, the patient is to be treated as full code...


Hmmm (what was his HR?)(HX?)
Unless I'm rustier than I thought, his patient would get CPR until atropine was on board and effective, reassess everything, High flow into BVM or CPAP until ROSC that was acceptable, reassess everything, and dopamine was in fact in our protocol. Pacing of course couldve been option, based on findings, obviously.

How'd I do?


Hey, BTW
does FORUM DEPUTY CHIEF under your name mean youre an administrator of this site? Im just curious.

 

[chaz90]

re:
Here's one for you: If your patient is clearly altered, has a heart rate of 22 and a BP that's barely palpable and is breathing 4 times a minute, are you going to start CPR? Are you going to hang dopamine or epinephrine, or put the patient on a pacer?This patient does have a valid DNR. This patient clearly isn't dead yet, so by your criteria, the patient is to be treated as full code...


Hmmm (what was his HR?)(HX?)
Unless I'm rustier than I thought, his patient would get CPR until atropine was on board and effective, reassess everything, High flow into BVM or CPAP until ROSC that was acceptable, reassess everything, and dopamine was in fact in our protocol. Pacing of course couldve been option, based on findings, obviously.

How'd I do?


Hey, BTW
does FORUM DEPUTY CHIEF under your name mean youre an administrator of this site? Im just curious.

You're significantly rustier than you thought. This patient (assuming an adult) has a HR and a palpable pulse, so no CPR. Also, CPAP for an altered hypotensive patient breathing 4 times/minute? Yeah, not so much. No atropine either since I'd probably jump straight to pacing on a patient this critical IF she were not a DNR. If they were a DNR, I'd look at the state and situation specific documents (as has been mentioned ad nauseam) to determine if pacing and BVM ventilations count as life support (hint: they probably do) for this patient.

Why is this so difficult for you?

 

[VFlutter]

How'd I do?

I think Chaz90 answered that. Personally I think that patient should be made comfortable and allowed to die. But what do I know, I am just a lowly EMT.

Hey, BTW
does FORUM DEPUTY CHIEF under your name mean youre an administrator of this site? Im just curious.

No, the title underneath the username is automatically generated based on your post count. Or you can create your own. The Admins have Red usernames

 

[Handsome Robb]

re:
Here's one for you: If your patient is clearly altered, has a heart rate of 22 and a BP that's barely palpable and is breathing 4 times a minute, are you going to start CPR? Are you going to hang dopamine or epinephrine, or put the patient on a pacer?This patient does have a valid DNR. This patient clearly isn't dead yet, so by your criteria, the patient is to be treated as full code...


Hmmm (what was his HR?)(HX?)
Unless I'm rustier than I thought, his patient would get CPR until atropine was on board and effective, reassess everything, High flow into BVM or CPAP until ROSC that was acceptable, reassess everything, and dopamine was in fact in our protocol. Pacing of course couldve been option, based on findings, obviously.

How'd I do?


Hey, BTW
does FORUM DEPUTY CHIEF under your name mean youre an administrator of this site? Im just curious.

Your treatment plan is downright scary.

How did CPAP even come up in that?

No, it changes with your post count. Administrators' names are in red.

 

[Akulahawk]

Let me see...

re:
Here's one for you: If your patient is clearly altered, has a heart rate of 22 and a BP that's barely palpable and is breathing 4 times a minute, are you going to start CPR? Are you going to hang dopamine or epinephrine, or put the patient on a pacer?This patient does have a valid DNR. This patient clearly isn't dead yet, so by your criteria, the patient is to be treated as full code...


Hmmm (what was his HR?)(HX?)
Unless I'm rustier than I thought, his patient would get CPR fail until atropine was on board and effective fail, reassess everything, High flow into BVM fail or CPAP fail until ROSC that was acceptable, reassess everything, and dopamine fail was in fact in our protocol. Pacing of course couldve been option, based on findings, obviously. fail

How'd I do? You just got reported to the EMSA for functioning outside your protocols. In short you failed at multiple points.


Hey, BTW
does FORUM DEPUTY CHIEF under your name mean youre an administrator of this site? Im just curious.

Forum Deputy Chief is a title based on achieving a certain number of posts. Post enough and you'll get that title too.

 

[Einstein]

btw
re larfge debate with dude about handling hr22 patient, i thought about it and remembered how many i had of these and realized it would be quite extreme situation where id jump on cpr for a moment prior to TCP

you were right.

that was a (likely, under most circumstances) a dumb thing to blurt out

but that doesnt mean its not sound under certain circumstances

 

[chaz90]

btw
re larfge debate with dude about handling hr22 patient, i thought about it and remembered how many i had of these and realized it would be quite extreme situation where id jump on cpr for a moment prior to TCP

you were right.

that was a (likely, under most circumstances) a dumb thing to blurt out

but that doesnt mean its not sound under certain circumstances

What are you trying to say here? I'm not trying to be rude, but I'm having a bit of trouble following your train of thought.

 

[Einstein]

EDITED FOR CONTEXT/CLARITY. (DEmedic)


To
Chaz90
Re; I don't remember thinking you're being rude.
re: train of thought...Hmmmm Not sure why it was confusing.

I realized i said something the about treatment the other day that, in retrospect, could have been a better answer and wanted to admit it. It was meant for someone else. I'm still learning this site and how my replies make it to the intended person. So i was just throwing it out there in case they were on line.

have a great one

 

[NomadicMedic]

Stay on topic please.

I've removed the off topic posts.

 

[eonefireemt3]

To me, I would have to agree. If I had a DNR. I would not want you to bag me. If I am suffering, maybe some pain management or sedation. No heroic measures. Beyond that, it falls within what is specified within the DNR and what your state considers to be heroic measures.