DNR, comfort measures, BVMs and OPAs

[crazycajun]

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.

DNR orders are fairly simple. OPA, NPA, ETT are considered advanced airway and cannot be used. BVM is for assisted ventilation and is also not allowed. If your PT is DNR w/ comfort measures only all you can do as a basic is give O2 via NC or NRB, use jaw thrust or head tilt to clear airway and comfort the PT along with family to the best of your ability. Any other methods could be construed as a violation against the order. Now if your PT is suffering from anything other than the disease in which the DNR is written for that is a different story. Like if your PT was choking on a piece of meat you could use advanced care because it is not the terminal disease killing him.

 

[Shishkabob]

An OPA and NPA, atleast here in Texas, are not considered advanced airways. I've put plenty of OPA's and NPAs in DNR patients without anyone so much as batting an eye.



Their DNR is in effect for ANYTHING that may kill them, not just their terminal disease it's written for. If they have hepatic cancer, but die from some other natural cause, you still are not to do anything.



The exception to this, as written word for word on the Texas OOH-DNR, is "This Out-of-Hospital DNR order is automatically revoked if the patient is known to be pregnant or in the case of unnatural or suspicious circumstance"

IE, if they are the victim of a crime, the DNR is not valid.

 

[TimBootz]

Interesting. Here in my county we are not allowed NPAs and OPAs are also not considered advanced airways like King, Combitubes or ETT.

 

[Tigger]

DNR orders are fairly simple. OPA, NPA, ETT are considered advanced airway and cannot be used. BVM is for assisted ventilation and is also not allowed. If your PT is DNR w/ comfort measures only all you can do as a basic is give O2 via NC or NRB, use jaw thrust or head tilt to clear airway and comfort the PT along with family to the best of your ability. Any other methods could be construed as a violation against the order. Now if your PT is suffering from anything other than the disease in which the DNR is written for that is a different story. Like if your PT was choking on a piece of meat you could use advanced care because it is not the terminal disease killing him.

I'd be careful about making blanket statements regarding DNRs. It is up to the individual states to create their own DNR protocol, and deviations among states certainly exist. For instance, the MA DNR is not written to include any specific medical condition. If the patient is in extremis and has a valid DNR, providers are not to attempt resuscitation.

Furthermore, in MA, palliative care is to be given to patients who are experiencing a medical emergency but still has a pulse and is breathing. This includes among other things, suctioning, IV initiation, and 12 leads.

I guess the take away here is: understand what your state's DNR protocol is.

 

[JPINFV]

Furthermore, in MA, palliative care is to be given to patients who are experiencing a medical emergency but still has a pulse and is breathing. This includes among other things, suctioning, IV initiation, and 12 leads.

I guess the take away here is: understand what your state's DNR protocol is.

Also, understand the nuances. For example, acute, non-related conditions, are often ok to treat. The typical example given is giving the heimlick to a patient with a FABO. Similarly, I'd argue that administering D50 to a hypoglycemic patient would be perfectly ethical.

 

[Aidey]

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

So like I said, it isn't only a DNR.

To the OP, it may be easier to think of the POLST form as two different forms.

 

[Tigger]

Also, understand the nuances. For example, acute, non-related conditions, are often ok to treat. The typical example given is giving the heimlick to a patient with a FABO. Similarly, I'd argue that administering D50 to a hypoglycemic patient would be perfectly ethical.

I would agree that D50 adminstration should be considered pallitave care since it would serve to make the patient more comfortable. That said any drug administration for someone with a DNR requires contacting medical control, from what I understand.

 

[TimBootz]

I have found the anwser I was looking for by going throught the CBT moduals. I have not yet taken the death and dying CBT but here is quote from it..

"The Dying Patient
On rare occasions, a patient with a terminal illness clearly may be dying on your arrival, but not yet in cardiac arrest. If the patient has requested that no resuscitation be performed, you should honor those wishes if cardiac arrest occurs. For example, you would withhold aggressive treatment such as chest compressions, bag-valve-mask ventilation or defibrillation. Always ask the patient or surrogate...Palliative Care
You can make a patient more comfortable with appropriate positioning, suctioning or controlling bleeding."


Thank you for everyones posts

 

[katgrl2003]

I would agree that D50 adminstration should be considered pallitave care since it would serve to make the patient more comfortable. That said any drug administration for someone with a DNR requires contacting medical control, from what I understand.

Why? DNRs are for when the heart stops or when they stop breathing. There are lots of things they cant have wrong that requires a medication you can give. Example: pain relief. We don't call for orders for pain relief with regular patients, and they only way I can see to call on a DNR patient is if they already have lots of pain meds on board.

 

[parapaulieFL]

Yeah it depends on each state. It sucks as a health care provider to watch a patient slowly die and not be able to do anything about it. The majority of DNR patients I have taken are in a hospice type care program and expect the outcome. The main issue is most people know this is coming and do not care to prolong the pain or suffering any longer. I have had a lot of these patients die en route, all you can do is make them comfortable.

 

[Akulahawk]

Yeah it depends on each state. It sucks as a health care provider to watch a patient slowly die and not be able to do anything about it. The majority of DNR patients I have taken are in a hospice type care program and expect the outcome. The main issue is most people know this is coming and do not care to prolong the pain or suffering any longer. I have had a lot of these patients die en route, all you can do is make them comfortable.

Which is the reason they're in hospice. For all of us, the end is inevitable. It's just a question of when and how. If I'm going to kick the bucket from some reason other than old age where one day I just "wake up dead" I would want some kind of comfort care to keep me comfortable while on my way out. Today, the dying process can be so drawn out, it's difficult to see when that final downward spiral begins in earnest. It used to be pretty obvious that someone was "on their deathbed."

 

[Tigger]

Why? DNRs are for when the heart stops or when they stop breathing. There are lots of things they cant have wrong that requires a medication you can give. Example: pain relief. We don't call for orders for pain relief with regular patients, and they only way I can see to call on a DNR patient is if they already have lots of pain meds on board.

Honestly, the best answer I can give is that it states exactly that in our statewide protocols. Whether or not this followed is beyond me, I work on a BLS truck and have yet to give anyone a BLS medication beyond prescribed oxygen to someone with a DNR. The paramedic crews may operate differently.


Sent from my out of area communications device.

 

[HotelCo]

If I, as a 21 year old male, have a valid DNR, and it's presented, or known to you, when I call 911 for a medical emergency, would you treat me if I had the following: (each one is to be considered a separate scenario)

Hypoglycemia?

Asthma?

Some sort of major trauma?

Respiratory arrest? What if you thought it was due to a narcotic OD?


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[JPINFV]

Hypoglycemia?

Asthma?

Some sort of major trauma?

Respiratory arrest? What if you thought it was due to a narcotic OD?


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Yes.

Yes.

Depends on the situation (before yellows, but at the end of the reds if multiple patients are present).

Depends (Causes immediately reversible such as narcotic ODs, however with the caveat that narcotic ODs due to pain management concerns, in contrast to accidental OD, would not be treated). Pretty much every DNR policy I've seen has directed providers to provide pain control even if it meant shortening the patient's life.

 

[Akulahawk]

I'd have to have paperwork or the medallion before I'd withhold care... if at all. My specific responses in red below.

If I, as a 21 year old male, have a valid DNR, and it's presented, or known to you, when I call 911 for a medical emergency, would you treat me if I had the following: (each one is to be considered a separate scenario)

Hypoglycemia? Yes.

Asthma? Yes if your DNR is not related to respiratory issues.

Some sort of major trauma? Depend upon whether or not you're already dead. However, in an MCI, as JP indicated, I'd put you at the back of the line for "Red" but before the "Yellow" groups. I guess you could call it a 'Delayed Red' and you'd be among the first alive but non-salvable to be put in the black category.

Respiratory arrest? What if you thought it was due to a narcotic OD? No and Narcotic OD unrelated to pain management orders MIGHT get narcan.


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All this assumes that I have legal evidence of your DNR status PRIOR to treating you.

 

[JPINFV]

Asthma? Yes if your DNR is not related to respiratory issues.

You know... I'd go as far as saying that a quick albuterol tx would be a comfort care treatment.

 

[Akulahawk]

You know... I'd go as far as saying that a quick albuterol tx would be a comfort care treatment.
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Being that the DNR policies I've seen specified cardiotonic drugs, if I had a patient who had a DNR and asthma and was having difficulty breathing because of the asthma, I'd right there with ya, for the same reason. The only reason I put in the "DNR not related to respiratory issues" was to address the possibility that someone's respiratory problems were the cause of the DNR/Care order that specifies that no respiratory meds were to be given...

Of course, then again, where's the line that we stop at? After all, isn't mag sulfate used in treating asthma? Since it's also used in cardiac resuscitation, is it "out" if it's used primarily for treating asthma in that instance?

Albuterol nebs I'm good with, but should that be limited to 2 or 3 treatments or is continuous neb Tx OK?

I guess it comes down to intent. If I intend to make the patient more comfortable, it's good but if the intent is to prevent a respiratory failure caused code... then I can't "do that" and provide whatever comfort care methods I'd have at my disposal.

 

[JPINFV]

Albuterol nebs I'm good with, but should that be limited to 2 or 3 treatments or is continuous neb Tx OK?

I guess it comes down to intent. If I intend to make the patient more comfortable, it's good but if the intent is to prevent a respiratory failure caused code... then I can't "do that" and provide whatever comfort care methods I'd have at my disposal.

I think these are the two big issues, how long does the treatment need and intent. Furthermore, it's a judgement call. I wouldn't say that a continuous neb would be appropriate, but how many before you stop is going to be situationally dependent.