DNR - NO Artificial Ventilation and the use of a BVM?

TheLocalMedic said:
You stole my response! DNR comes into play once they are in cardiac or respiratory arrest. Until they reach that point, it's treatment as you would for anyone else. Yes, even patients in resp failure get a BVM. Once they completely stop breathing, then you can follow the DNR wishes.
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Ummm...again, not in the state of Texas.
 
usalsfyre said:
Ummm...again, not in the state of Texas.
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I suppose it's a matter of interpretation based on the situation though. Sure, if someone is circling the drain because they're simply dying and have a DNR in place, I wouldn't ventilate them. But how many times have you seen people on Hospice care who have DNRs in place who experience a sudden acute illness that they want treatment for? Like a guy dying from liver failure experiencing an severe allergic reaction (happened to me). I would, and did, absolutely treat that acute illness with everything I had, including giving epi and assisting his breathing with a BVM and in-line neb. They guy was planning on going out, but not like that. He improved quickly and was grateful that we helped him.
 
usalsfyre said:
Texas uses DNRs/DNIs. The legal wording spells out that artificial ventilations (even to assist a patient still breathing) is considered "life prolonging" and therefore verboten.
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NM EMS DNRs are worded the same way
 
I think every state has a "living will" and/or advanced directive statute. A living will is an advanced directive from the patient. That statute is usually pretty specific, and frequently gives the wording used in the form that is signed by the patient. Closely related and frequently completed at the same time are the Durable Power of Attorney for Healthcare, giving a specific person or persons the right to act if the patient cannot. Every hospital is supposed to ask every patient if they have one, and if they don't, would they like to have one? Those forms are very specific on what is and is not appropriate and what treatment may or may not be given to the patient. Patients already in hospice care should have one available.

A DNR and living will are NOT the same thing. A DNR order is an order from a physician, mainly used in a hospital, but I'm assuming would also be found in nursing homes.
 
broken stretcher said:
Is the pt conscious? Then the DNR doesn't matter until this changes.
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It does matter, we are supposed to be patient advocates and doing what the patient wants or would want done to and for them. This all or nothing approach in EMS is absurd and really shows a lack of critical thinking and ability to make judgement calls. I am treating a treating a 45 year old respiratory failure with no DNR differently from a 98 year old respiratory failure with a DNR, even if both of them are conscious. I don't just throw the protocol book at everyone who is still breathing because I can.

In most cases patients in the elderly age group do not want every treatment you can throw at them even if they aren't DNR's. And before someone jumps in and says that's not our decision...it absolutely is. In my humble opinion treating someone more than they would want knowingly (even in an impaired patient) is just as bad as withholding treatment. In cases where it isn't black and white there is often quite a bit of evidence of what a person wants done or doesn't want done. It shouldn't be a "do everything unless the patient is alert and oriented". It should be a "The patient isn't alert and oriented...based on the findings and other people I have on scene what do I think this patient would want done".

Be a patient advocate, do what you think the patient would want.
 
If a patient decides not to follow through on a DNR and demands care, you give it. IF they then lose consciousness, the latter decision, if competent, is followed. It's like a codacil on a will.

I'm cheered to see no one used the old "just wait until they lose consciousness" dodge.

Resp distrees versus failure:

Distress: I can't breath properly.
Failure: I can't breathe effectively at all.
Distress is a possible sign of impending failure. Failure is a sure sign of impending death.

Clinical signs, and not just semantics until we're comfy at our keyboards.
 
broken stretcher said:
Is the pt conscious? Then the DNR doesn't matter until this changes.
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It matters a LOT! IF my DNR patient is actually conscious, then the patient has the ability to request that I ignore the DNR or they can agree to a specific treatment plan that I propose that ignores the DNR. If the patient is not conscious, then I can only go by what's stated in the DNR and my protocols about said DNR.
 
Rialaigh said:
It does matter, we are supposed to be patient advocates and doing what the patient wants or would want done to and for them. This all or nothing approach in EMS is absurd and really shows a lack of critical thinking and ability to make judgement calls. I am treating a treating a 45 year old respiratory failure with no DNR differently from a 98 year old respiratory failure with a DNR, even if both of them are conscious. I don't just throw the protocol book at everyone who is still breathing because I can.

In most cases patients in the elderly age group do not want every treatment you can throw at them even if they aren't DNR's. And before someone jumps in and says that's not our decision...it absolutely is. /QUOTE]

This is a dangerous line of thinking, in my opinion. You can't assume that just because a patient is old or someone is impaired that they don't want treatment. They may have a DNR, but that isn't the same as wanting to die. You have to assume that they want to live, and then follow the DNR wishes if they actually tank.
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Maybe I miss it but what we're his lung sounds, everyone accessing cpap but that won't help in asthma.
 
Hunter said:
Maybe I miss it but what we're his lung sounds, everyone accessing cpap but that won't help in asthma.
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CPAP can actually help greatly in asthma patients. It can decrease their work of breathing, help splint the airway, and can be used with inline nebs.
 
Second. It's used with nebulized meds frequently. I believe prehospital CPAP is amazing and is the ONLY "ALS skill" that should be given to basics.
 
Hunter said:
Maybe I miss it but what were his lung sounds, everyone accessing cpap but that won't help in asthma.
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Given that the OP was treating with Albuterol and Atrovent, we can only take an educated guess that there was some kind of reactive airway problem going on, probably asthma. Using a BVM is a very poor-man's way to create a CPAP-like situation. Unless there's a very good mask fit and there's a PEEP valve on it, a BVM isn't going to come anywhere close to being able to truly approximating a CPAP system.

CPAP does apparently work a bit better than a NRB alone in these patients in ensuring appropriate ventilation. These patients are probably the #1 reason why CPAP was finally approved for field use by Paramedics. I would prefer to use CPAP with a mixed gas (such as heliox) in these patients so that I can keep them from having to be intubated and/or put on a vent because of the issues that go along with being intubated and being on a vent.

On top of it all, you can do in-line nebs of patients that are on a CPAP and because of the pressure support, whatever's being nebulized should reach further down the respiratory tract and have a greater effect than it would otherwise.
 
TheLocalMedic said:
All of the above… or more succinctly: Ditto :)
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IF anyone is into really deep diving, you'll know what I mean about using heliox (or for that matter, a tri-mix). When going DEEP, there's both issues of partial pressures to deal with and atmospheres of just nitrogen and oxygen can get quite dense, though probably only our lungs would notice that effect. Over the years, I've run across some RT's that were strong proponents of using mixed gasses in conjunction with CPAP for those very difficult to ventilate patients. IIRC, a hospital just south of me (St. Joseph's in Stockton) did their own study about 10-12 years ago and found that by using mixed gasses in this population, they were able to either keep patients off the vent entirely OR reduce the number of days on the vent by about 3 days, including weaning time. I no longer have a copy of their results handy (it's been that long) but their findings have stuck with me since.

Oh, and thanks for the "ditto!"
 
I USED TO have my EMT, but it’s been 10 years since I had to let it lapse due to work situation, but… I am in my 3rd year of law school, and wanted to chime in on this issue.

Normally, a “DNR” order means exactly that. If the patient, or their legal representative, has signed a valid DNR order, does that mean you can’t do ANYTHING to keep that patient alive, or does that mean you can, as has been suggested, used “passive” methods like a mask or cannula, but not “artificial” methods like a BVM, intubation, CPR, etc.?
 
DEmedic said:
Second. It's used with nebulized meds frequently. I believe prehospital CPAP is amazing and is the ONLY "ALS skill" that should be given to basics.
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In Pa its BLS skill for those who completed the training and the squads that are participating in the program.

As a provider theres a 4 hour class you must take, Medical Director must approve it, and theres a whole QA process to participate in after the call is completed. Its proven to have its advantages as in some areas a ALS intercept may be 30 minutes away.
 
Have we digested the inadvisability of bagging (resuscitating) someone with a DNR unless they say themselves to go ahead?
 
mycrofft said:
Have we digested the inadvisability of bagging (resuscitating) someone with a DNR unless they say themselves to go ahead?
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There seems to be considerable regional variations in terminology.

Where I was trained (NYS), a DNR does not kick in until the patient loses pulses and/or spontaneous respirations. Up until that point, you treat them just like every other patient, meaning assisting with ventilations and even intubating if indicated, along with pressors, blood, surgery, and other resuscitative measures.

If they don't want ventilation or intubation or pressors, then that requires a different type of advanced directive. A DNR itself does not apply until a respiratory or cardiac arrest has occurred.
 
Generally speaking, you are probably correct in that a DNR “does not apply until a respiratory or cardiac arrest has occurred.”

However, there are also probably regional variations as to what constitutes a valid DNR request, and it is also possible that a DNR order could be “customized”, in that you can do THIS but you can’t do THAT.

I am only familiar (somewhat) with California law.
 
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