DNR orders

[Pittsburgh Proud]

After reading the AMR thread this comes to mind. Just something to talk about.
I enjoy doing on line con ed. I have way more that I ever need to recert but I like doing them in the evening to relax and learn.
I did a con ed on DNR Orders here in PA and I understand each state might be diffrent but here is something to talk about.

In this lesson it was mentioned that we (the Ems) need to have the "original" DNR order in the truck for it to be valid to start with and in the video they even say good luck trying to get the "original".
I work at two different services and the one we do a fair about of bls transports. I get Copies of DNA orders all the time. Well after taking this class I talked with one of our white shirts in the company about this. I was concerned because the chance of someone expiring on me is pretty high. I ask what is the procedure for me to follow in this situation? I have a copy of the order but technically it is not valid because it IS a copy.
I was told if something were to happen to do nothing to the pt. call for als right away and they can call command. Not sure I care for that answer but better to be on there shoulders than mine.
I have to admit I'd call als and my second call would be command myself.

Any thoughts or comments on this? :unsure:

 

[KEVD18]

thats a completly bs policy and heres why:

if your company had a policy in place, your supe would have pointed you toward it. "call command" is equivalent to "i dont know, but i want to sound like i do, so heres a really snazzy answer". if command will tell you not to work the code, why call als at all? and if your going to work the code, why call command(except of course to request als)? and whats happening with your cardiac arrest patient while your making all these radio/phone calls? is cpr in progress? if it isnt, what if command takes say two minutes to make a decision. that patient just lost tissue....

call your state ems board and get the real answer.

in ma, the regulations were recently revised to allow us to accept photocopies as originals with no further verification. priuor to that change, we could transport with a copy carrying the validity of the original only if we had physically seen the original that day. one of my former regular renal pt's kept a copy in her dialysis bag and the original taped to the kitchen cabinet...

 

[JPINFV]

I don't view calling command as a cop out from the company. That could be the only legitmate answer if a copy is not considered to be a valid DNR order. The company is simple between a rock and a hard place when trying to honor the patient's wishes. If this is the case, I doubt that the EMS board is going to offer any better advice outside of online medical control.

In California, DNR rules vary by county. In the county I worked in, photocopies were allowed, as well as verbal physician orders, signed written orders for patients in care facilities, as well as verbal requests from immediate family members. In addition, face sheet style DNR notations were acceptible from facilities that used only computerized orders with this clarification coming from county EMS. Any concerns or disagreements were supposed to be advanced to online medical control, but basics did not have that option. Thus, if there were any concerns with patients being treated by basics, the patient was either supposed to have paramedics called or transport as if the patient didn't have a DNR.

 

[Pittsburgh Proud]

thats a completly bs policy and heres why:

if your company had a policy in place, your supe would have pointed you toward it. "call command" is equivalent to "i dont know, but i want to sound like i do, so heres a really snazzy answer". if command will tell you not to work the code, why call als at all? and if your going to work the code, why call command(except of course to request als)? and whats happening with your cardiac arrest patient while your making all these radio/phone calls? is cpr in progress? if it isnt, what if command takes say two minutes to make a decision. that patient just lost tissue....

call your state ems board and get the real answer.

in ma, the regulations were recently revised to allow us to accept photocopies as originals with no further verification. priuor to that change, we could transport with a copy carrying the validity of the original only if we had physically seen the original that day. one of my former regular renal pt's kept a copy in her dialysis bag and the original taped to the kitchen cabinet...

I wonder what liability we (as emt's) would assume if we just worked it from the get go?
I mean in the lesson it was pretty clear to me that NO copies were to be accepted.

I totally agree with you on the time issue.

 

[JPINFV]

I wonder what liability we (as emt's) would assume if we just worked it from the get go?

Probably none. No valid DNR=no DNR. All of the DNR policies that I've seen included the note that any concerns or disagreements would have resuscitation started pending orders from medical control. It's much easier to stop resuscitation after waiting 2 minutes for a decision from a base hospital physician, then to start resuscitation after 2-3 minutes of doing nothing.

 

[Pittsburgh Proud]

Probably none. No valid DNR=no DNR. All of the DNR policies that I've seen included the note that any concerns or disagreements would have resuscitation started pending orders from medical control. It's much easier to stop resuscitation after waiting 2 minutes for a decision from a base hospital physician, then to start resuscitation after 2-3 minutes of doing nothing.

Point well taken. I would much rather error on the side of caution and be safe than sorry. I mean it is a person's life we are talking about and I saw no "grey area" here it sounded cut and dry to me but yet day after day I get copies and never the original.

 

[KEVD18]

you need an iron clad, no bs answer, in writing(either a state a/r or company policy manual)

no liability? thats laughable. heres two scenarios to think about:


patient transferring from snf to dro for routine appt. you arrive and grab their chart to do your paperwork. you get to the dnr box, so logically you flip to the advanced directives section of the chart. there some other stuff that has been misfiled in there but after digging a bit you find a xerox of the dnr, so you jot down the number and away you go. what you dont know is that the patient had that dnr written when there was little hope of improvement in their condition. but alas, they're going to get that kidney after all! hurray! tear that sucker up. so whomever is tasked to do so opens the chart, flips to ad's and right on top is the original. rip rip, done(except for that pesky misfiled xerox that you found right??) fast forward: cardiac arrest. if you work it, your in accordance with the patients wishes. if you dont, you just sat there and watched someone die...

now flip that over. they're not getting the kidney. they're going to die, very soon, and they or ok with that. they've made their piece with whomever, said goodbye to distant relatives and what not. they've accepted it. you come along to do the same call. all you find is that copy. you flip and flip through but its just nowhere to be found(except that some haitian creation filed it under menu preferences). so you think, well i cant take a copy so maybe its like i read about on emt life that time. so you check the box "full code" and go on about your call. fast forward: cardiac arrest. you work it feverishly, call for medics(or maybe you are medic by then) you get them back!!! kudos to you good sir they roll into the er maintaining a pulse and a pressure. now fast forward again: coma. they lost just enough brain tissue to never do much more than cost a fortune in intensive care, but kept enough to "live" for a while. in ma, you would be sued by the family and you would lose.

get a concrete answer. its out there, its just a matter of finding it. the state will know, since they make the rules

 

[JPINFV]

patient transferring from snf to dro for routine appt. you arrive and grab their chart to do your paperwork. you get to the dnr box, so logically you flip to the advanced directives section of the chart. there some other stuff that has been misfiled in there but after digging a bit you find a xerox of the dnr, so you jot down the number and away you go. what you dont know is that the patient had that dnr written when there was little hope of improvement in their condition. but alas, they're going to get that kidney after all! hurray! tear that sucker up. so whomever is tasked to do so opens the chart, flips to ad's and right on top is the original. rip rip, done(except for that pesky misfiled xerox that you found right??) fast forward: cardiac arrest. if you work it, your in accordance with the patients wishes. if you dont, you just sat there and watched someone die...

You're asking for the ambulance crew to be psychic and/or read minds. If a copy is considered a legitimate DNR (which is not the case in this instance anyways), then how is an ambulance crew supposed to know if it's been revoked? The simple answer is that you have nothing better to go on most of the time other than what is in the chart. IF a valid DNR is present when there shouldn't be one, then the liability should fall on the facility responsible for maintaining the chart, NOT the ambulance crew that doesn't have time to sit around giving a patient or their family the 3rd degree over what is/isn't in a file that they do not maintain (the facility does).

now flip that over. they're not getting the kidney. they're going to die, very soon, and they or ok with that. they've made their piece with whomever, said goodbye to distant relatives and what not. they've accepted it. you come along to do the same call. all you find is that copy. you flip and flip through but its just nowhere to be found(except that some haitian creation filed it under menu preferences). so you think, well i cant take a copy so maybe its like i read about on emt life that time. so you check the box "full code" and go on about your call. fast forward: cardiac arrest. you work it feverishly, call for medics(or maybe you are medic by then) you get them back!!! kudos to you good sir they roll into the er maintaining a pulse and a pressure. now fast forward again: coma. they lost just enough brain tissue to never do much more than cost a fortune in intensive care, but kept enough to "live" for a while. in ma, you would be sued by the family and you would lose.

Again, EVERY DNR protocol I've seen clearly states that in the absence of a valid DNR or concerns over the legitimacy of a DNR that the patient is supposed to be worked pending orders from medical control. If the nursing home can't produce a valid DNR, and failing other routes of confirming the patient's wishes, then the patient is not a DNR unless medical control says otherwise. If basics aren't allowed to contact medical control directly, then the patient might as well be a full code as far as a basic level ambulance is concerned.

Would you like me to post a link to my county's DNR protocol for use as an example?

Actually, let's quote the Mass EMS DNR ("Comfort Care") protocol.

If EMS personnel have any question regarding the applicability of the CC/DNR Order Verification with regard to any specific individual, the EMS personnel shall:

* verify with the patient, if the patient is able to respond;
* provide full treatment; or,
* contact Medical Control for further orders.

http://www.mass.gov/?pageID=eohhs2t...services_p_comfort_care_overview&csid=Eeohhs2

Now, yes, any actions in terms of dealing with DNR care should be verified with local government agencies. I never said that it wasn't, but what I did say was that calling medical control might be the only solution possible. The simple fact is that action must be taken on DNR calls, be it sit back and honor the DNR in whole, or begin treatment. Time simply does not stand still while crews try to figure out if a DNR is or is not valid.


So now, I ask you. You have a patient who "has" a DNR (either an invalid DNR is present or the nursing staff tells you that the patient has one, but can't produce it), but no valid DNR can be produced. Your location doesn't allow EMT-Bs to contact online medical control, what do you do?

 

[JPINFV]

You know what, I've got a really simple solution.

Google Pennsylvania EMS.

->EMS protocols
->search DNR

Solution:

OUT-OF-HOSPITAL DO NOT RESUSCITATE
STATEWIDE BLS PROTOCOL
Criteria:
A. Patient displaying an Out-of-Hospital Do Not Resuscitate (OOH-DNR) original order, bracelet,
or necklace who is in cardiac or respiratory arrest.1
Exclusion Criteria:
A. Patient does not display, and patient surrogate does not produce, an OOH-DNR original order,
bracelet, or necklace.
B. An OOH-DNR order may be revoked by a patient or their surrogate at any time. If the patient or
surrogate communicates to an EMS practitioner their intent to revoke the order, the EMS
practitioner shall provide CPR if the individual is in cardiac or respiratory arrest.
C. Advance directives, living wills, and other DNR forms that are not valid Pennsylvania
Department of Health OOH-DNR orders may not be followed by EMS personnel unless
validated by a medical command physician. When presented with these documents, CPR /
resuscitation should be initiated and medical command should be contacted as soon as
possible.
D. Patient is not in cardiac or respiratory arrest.
Treatment:
A. All patients in cardiac or respiratory arrest: 2
1. Follow Scene Safety protocol #102 and BSI precautions.
2. Verify the presence of a valid PA DOH OOH-DNR original order, bracelet, or necklace.
a. If there is any question of whether the OOH-DNR order is valid, the patient or their
surrogate has revoked the order, or whether the patient is pregnant3, the EMS
practitioner shall:
1) Initiate resuscitation using appropriate protocol(s), and
2) Contact medical command as soon as possible
3. Verify pulselessness or apnea.
4. If a bystander has already initiated CPR:
a. Assist with CPR and contact medical command immediately.
5. If CPR has not been initiated before the arrival of EMS personnel:
a. The OOH-DNR shall be honored and CPR shall be withheld or discontinued.
b. Contact the local coroner or medical examiner.
Possible Medical Command Orders:
A. The medical command physician may order termination of resuscitation efforts if CPR was not
initiated by EMS personnel.
Note:
1. EMS personnel shall follow this protocol and, when appropriate, shall honor an OOH-DNR within a
hospital.
2. An OOH-DNR order, bracelet or necklace is of no consequence unless the patient is in cardiac or
respiratory arrest, if vital signs are present, the EMS practitioner shall provide medical interventions
necessary and appropriate to provide comfort to the patient and alleviate pain unless otherwise
directed by the patient or a medical command physician. Follow appropriate treatment protocols.
3. For pregnant patients, the EMS personnel shall examine the original signed OOH-DNR to ensure
completion of Section 2B “Physicians for Pregnant Patients Only” by the patient’s attending
physician in order to honor the OOH-DNR and withhold or discontinue CPR.
Performance Parameters:
A. Review all cases for documentation of presence of a PA DOH recognized OOH-DNR order,
bracelet, or necklace.

http://www.dsf.health.state.pa.us/health/lib/health/ems/bls_protocols_2004.pdf
page 41

No valid DNR and can't make base hospital contact, the patient gets worked.

 

[KEVD18]

your missing my whole point. the OP's service hasnt officially determined what determines validity.

if copies are valid, then so be it. if they are not, then so be it. but being ambiguous about it will drop you right flat into that or a similar scenario.

im not saying calling med control is a bad thing. im saying that the policy need to be nailed down, thus relieving you of the responsibility of calling them at all.

copies are ok: so now you can accept the original or a copy. great. problem solved. patient codes and you have either, done deal.

copies are not valid: so you need the original. dont have it, inform both the patient and the staff that, unless they produce the original, the order isnt valid.

we're not talking rocket science here, but without an explicit, written policy this is a bloody minefield.

 

[KEVD18]

well with the posting of the op's state protocols on the matter(thank you) it would seem that it is spelled out quite clearly. a copy is in no way shape or form valid. that would fall under the auspices of no original order present, pt gets worked, no call to command or med control necessary(other than of course ask for medics, get orders for a tx etc)

 

[Pittsburgh Proud]

well with the posting of the op's state protocols on the matter(thank you) it would seem that it is spelled out quite clearly. a copy is in no way shape or form valid. that would fall under the auspices of no original order present, pt gets worked, no call to command or med control necessary(other than of course ask for medics, get orders for a tx etc)

See that's what I'm saying in the lesson it was clear also but yet day after day we get those copies.

Bottom line is I work them. The copy is no good.

Thanks for the discussion. I thought it was something good to talk about. It seems every place is different.

 

[KEVD18]

uuummm you might want to get a better handle on things than that. your current strategy tosses you right smack in the middle of a moral dilemma. you know your patient doesnt want to be worked, but your going to do it anyway because of a paperwork snafu???

as i said, tell the supervisor on the floor to get you the original because the copy cant be honored. if the patient originates at the residence, inform them they need the original. some arent aware(remember the patient i told you about with the original taped to the kitchen cabinet? it was put there by me after i told her i couldnt accept the copy without visualizing the original. she was very happy i told her...).

or start figuring how to deal with having worked a code(and possibly reviving into a persistent vegetative state) on a patient you blatantly knew didnt want heroic measures....