DNR, comfort measures, BVMs and OPAs

[TimBootz]

A question: I had a pt who was DNR and comfort measures only. The pt was a 77 y/o male w/ SOB 2^ to end stage COPD. This pt actually had a POLST with instructions pretaining to no intubation and was due to enter hospice care in 1 weeks time. I know that with comfort measures you can still admin O2 just no CPR. When a pt is comfort measures only can you still assit ventilations with a BVM? can you use OPAs or NPA's or are you only suppose to use passive O2 such as a NRB. Fortunately this pt managed to maintain with a NRB @ 10 l/min till we reached the ER which was only 6 min away. Pt. was a medic eval cleared for BLS tx. I had the BVM ready in case. I know it is more defensable to do something rather then nothing but the call got me to thinking....

 

[MrBrown]

Based on Brown's clinical and legal framework, no assisting ventilations is not "comfort measures"

Your framework may differ

 

[TimBootz]

Mr Brown can you clarify. Are you saying that in your frame work assisting ventilations (and by extension OPAs) is not ok when a pt is comfort measures only?

 

[JPINFV]

I know it is more defensable to do something rather then nothing but the call got me to thinking....

Either can be equally defensible or indefensible based on what you knew and what a reasonable EMT would have known. I wouldn't think that a battery charge (or, which is more likely, the civil suite for any additional medical care received) in a case where a patient had a valid POLST/DNR order that a medical provider, including EMTs, knowingly disregarded without good cause (which is normally defined). Every set of protocols (be it service protocols, region, or state) should have a policy on how to handle patients with DNR, and if you haven't read it yet then that ignorance is your own fault, not your company's or your schools.

 

[MrBrown]

Gosh mate "Mr Brown" sounds so formal, Brown or Your Royal Excellency will suffice

We have significant legal and praxis differences than the US, we do not work to "protocols" and there is much discretion left up to the professional clinical judgement of the Ambulance Officers on scene.

In saying that, if a patient has a DNR, living will or clearly articulated advanced directive (verbal or written) or themselves makes the request they do not want any life sustaining measures it is inappropriate for us to initiate measures aimed at doing that - for example relief of pain is appropriate whereas IV fluid or assisted ventilation are not

 

[usalsfyre]

So less a "legal" question and more a "moral" question, but WHY would you BVM this patient? The point of comfort care and DNR is that death is if not exactly welcome than an expected event.

Don't be 100% sure of how defensible wrongful recusitation.

 

[TimBootz]

Forgive my "ignorance" of the issue, which is why I am posting this here, in an effort to gain a better understanding of the issue, and what other BLS provider would consider prudent. The medics relased the pt to bls txpt because they said they would be unable to intubate the pt.

The protocols for 2010 in my county pretaining to DNR are written like this,
after the lengthy secton on documentation

"DNR" does not mean "do not care". A dying pt for whom no resuscitation effort is indicated can still be provided with support care, which may include the following:

Clear the airway (including stoma) of secretions
provide O2
control any bleeding
provide emotional support to pt and family
contact Pt MD
contact hospice if involved
Paramedics should be called if additional judgement or support is needed.

WHEN IN DOUBT, INTIATE RESUSCTATION (actually written in all caps and bold)

I have sent some emails out pretaining to the same question here in my county.

The call got me thinking that it is something that I need more information on for if/when confronted with the same situation in the future.

 

[usalsfyre]

Ventilating a patient isn't really "providing O2". It's using artificial measures (in this case ventilations) to extend life. This is true whether it's through an endotracheal tube or a mask.

Sorry for being contrite. It's not your fault EMS education is jacked.

 

[Sasha]

Artifical ventilation is life support. So dont bag a DNR patient.

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[JPINFV]

Forgive my "ignorance" of the issue, which is why I am posting this here, in an effort to gain a better understanding of the issue,

There's nothing wrong with ignorance. I'm fairly ignorant of quantam mechanics and fire fighting myself (among plenty of other fields of ignorance). Ignorance also has the wonderful trait of being fixable.

and what other BLS provider would consider prudent. The medics relased the pt to bls txpt because they said they would be unable to intubate the pt.

The protocols for 2010 in my county pretaining to DNR are written like this,
after the lengthy secton on documentation

"DNR" does not mean "do not care". A dying pt for whom no resuscitation effort is indicated can still be provided with support care, which may include the following:

Clear the airway (including stoma) of secretions
provide O2
control any bleeding
provide emotional support to pt and family
contact Pt MD
contact hospice if involved
Paramedics should be called if additional judgement or support is needed.

WHEN IN DOUBT, INTIATE RESUSCTATION (actually written in all caps and bold)

Is positive pressure ventilation listed? Is there any doubt to the validity of the DNR? Did you try contacting hospice (just because the patient isn't "in hospice" doesn't mean they aren't receiving hospice care) or the patient's physician? Did you ask the paramedics about PPV? Is online medical control an option that you could avail yourself to (it isn't always an option...)?

Additionally, you'll be surprised the amount of people who don't read the policy statements that are in the protocol book like this.

 

[JPINFV]

Sorry for being contrite. It's not your fault EMS education is jacked.

Given that the applicability of DNRs can vary wildly (everywhere from "only the orange colored official "prehospital DNR" form counts to being able to take verbal requests from immediate family members), if someone doesn't look up their local policy regarding patients with DNRs then it isn't the fault of their education program.

 

[bigbaldguy]

Just FYI dnr's are not generally honored on commercial aircraft unless lots of paperwork is done first.

 

[BEorP]

Just FYI dnr's are not generally honored on commercial aircraft unless lots of paperwork is done first.

Do you have a link to where I can read about this? It seems like by the time they could actually get the plane down, any further resuscitation efforts would be futile if the AED was already used without success.

 

[Aidey]

I found WAs POLST form online. Seeing as BiPAP/CPAP are listed as limited interventions, I would take that to mean that BMV is definitely NOT comfort measures. I don't think a BVM, OPA or NPA falls under "manual treatment of airway obstruction".

http://www.wsma.org/files/Images/PatientResources/Polst_form1.gif

 

[ffemt8978]

I found WAs POLST form online. Seeing as BiPAP/CPAP are listed as limited interventions, I would take that to mean that BMV is definitely NOT comfort measures. I don't think a BVM, OPA or NPA falls under "manual treatment of airway obstruction".

http://www.wsma.org/files/Images/PatientResources/Polst_form1.gif

Correct, although most POLSTs that I've seen usually detail what is acceptable for airway measures.


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[TimBootz]

Thank you that clears things up. I had not thought of it in the sense of CPAP and BiPAP, being they are machines as opposd to a BVM which is manual.

What I was thinking with my pt was he was still A+O spaeking in 2 word sentences (so havig a conversation with him was not really an option just yes and no questions) and had incresed work of breathing with diminshed volume and incresed resps. The pt was also doing a home neb treatment when I arrived on scene. I had always considered DNR and "after they stopped breathing or their heart stopped" measures.

I am also going to have a discussion with my companies med director when I get back on rotation next week.

Thank you for all the replies.

 

[Aidey]

The POLST form is not just a DNR though. Section B specifically states "Person has pulse and/or is breathing".

 

[bigbaldguy]

Do you have a link to where I can read about this? It seems like by the time they could actually get the plane down, any further resuscitation efforts would be futile if the AED was already used without success.

Just what I was taught at my airline and what folks at other airlines are taught as well. It is actually fairly common for a passengers family to Present a DNR before a flight. I've only seen one DNR presented at gate that we were told to "honor" by the higher ups and this was because a long process of paper work had been taken care of. I think the main reason for this is that as flight attendants we do not have the knowledge to decide if a DNR is valid or not. Theoretically we can call the medical advisor to verify the validity of a DNR but by the time a patch was made we would most likely have either successfully used the AED or there would be no point. I know we had a situation a few years back where a DNR was presented by family when a passenger died on a flight. The crew tried to perform CPR Ect.. The family was not happy but since the crew are considered lay responders there were no repercussions.
It does bring up the interesting question of what I would do if I was on a flight with a pax who coded and a DNR was presented. step back and let my crew do their thing I guess.

 

[ArcticKat]

Here's my take

My rule of thumb is that if I have to put something into the patient, it is not a "Comfort Measure", it's a treatment. Putting in an OPA, or using a BVM to put in air, would not be a comfort measure in my books and therefore exceeding the requests of the patient.

Administering oxygen via NRB or NC is a comfort measure. Hydrating PO is a comfort measure.

The only situation where I relax this rule of thumb is IV access for medications and hydration and foley caths.

 

[ffemt8978]

The POLST form is not just a DNR though. Section B specifically states "Person has pulse and/or is breathing".

And Section A has a specific section about no pulse/not breathing.