DNR Question

[Hockey]

If a patient has a valid DNR, and they are having inadequate breathing, does the DNR apply to lets say bagging them? How bout not breathing? Does DNR only apply to CPR/Shocking interventions?


I have a difficult partner that thinks she knows everything and was wondering what the correct answer is

 

[Epi-do]

DNR = Do Not Resuscitate NOT Do Not Treat

If the patient is not in cardiac arrest, you must treat them exactly as you would any other patient that does not have a DNR. The terminal cancer patient should be treated for the asthma attack they are having. The terminal cancer is the reason for the DNR, not the asthma. (Or whatever situation you want to come up with. This was just the first example I thought of.)

This is a sore point with me. I really don't understand how so many providers arrive at the conclusion that do not resuscitate = do not treat. GRRRRR

 

[Hockey]

Thank you because she was trying to state that was "Resuscitating" the patient and can get us in trouble if we did that.

She is the absolute worst partner you can imagine. Seriously. You know what a Jr Coder is right? She is the Chief Coder.

Had a PI the other day on the freeway and she said she can't get out of the truck because "scene isn't safe yet"

We were the first on. Freeway was already jammed pack. It was pretty safe. So I jump out tell her to grab the backboard and collar and go to the rollover vehicle. I look back before I got to the patient and told her to get out of the truck (nicely of course) and I hear her on the radio going "Dispatch scene not safe we need PD out here NOW!"

Then she was flipping out because the coolant was leaking and told me we almost died after the call.


Yes I went to supervisors about her but for some reason she still works here. Yes I went online and verified she DOES have a license. Scary...

She does know her stuff, she just can't apply it in real life....

 

[Scout]

Just on that and lightly of topic,

as scence safety is subjective, what could or can be done to someone who is overcautious, surely it would be very hard to say with asolute certantly that the scene was safe and to have anything done about it.

to her the cooling fluid may have been petrol? or anything esle that presents a legitimate hazard.

 

[JPINFV]

DNR = Do Not Resuscitate NOT Do Not Treat

If the patient is not in cardiac arrest, you must treat them exactly as you would any other patient that does not have a DNR. The terminal cancer patient should be treated for the asthma attack they are having. The terminal cancer is the reason for the DNR, not the asthma. (Or whatever situation you want to come up with. This was just the first example I thought of.)

This is a sore point with me. I really don't understand how so many providers arrive at the conclusion that do not resuscitate = do not treat. GRRRRR

Ahh, but there's the issue. In general DNR orders include prohibition against mechanical ventilation, advanced airways, and a whole slew of other interventions. Sure, if a patients is having an asthma attack go for the albuterol, but once the patient goes into respiratory and/or cardiac arrest, regardless of etiology, then the it's game over.

 

[Epi-do]

Ahh, but there's the issue. In general DNR orders include prohibition against mechanical ventilation, advanced airways, and a whole slew of other interventions. Sure, if a patients is having an asthma attack go for the albuterol, but once the patient goes into respiratory and/or cardiac arrest, regardless of etiology, then the it's game over.

Yes, you are correct. I should have qualified my answer with "in my area." Here, while in the hospital you may choose from an entire smorgasboard of options for your DNR. However, in the field, for EMS it is all or nothing. We are not allowed to only do compressions, or only push meds, or only *insert any other option here.*

If, as the OP asked, the patient is having inadequate respirations, but they still have some respiratory effort, we are obligated to bag them and provide appropriate airway management. Likewise, if they are in respiratory arrest, but not cardiac, we are obligated to do what we can. If, for instance, the respiratory arrest is due to an obstructed airway, we are expected to do what we can to open the airway and ventilate. If the patient continues to deteriorate, once their heart stops and they are in cardiac arrest, only then are we able to cease efforts.

 

[JPINFV]

Likewise, if they are in respiratory arrest, but not cardiac, we are obligated to do what we can. If, for instance, the respiratory arrest is due to an obstructed airway, we are expected to do what we can to open the airway and ventilate. If the patient continues to deteriorate, once their heart stops and they are in cardiac arrest, only then are we able to cease efforts.

I'm curious then because that's not what the Indiana prehospital DNR form states.

I direct that, if I experience cardiac or pulmonary failure i a location other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that I be permitted to die naturally.

http://www.in.gov/icpr/webfile/formsdiv/49559.pdf

In terms of picking and choosing, I think you missed my point. Where I'm currently working a DNR is also an all or nothing order. At the same time it specifically prohibits certain interventions such as intubation, mechanical ventilation, and the like.

 

[BEorP]

In Ontario, we would not bag someone who has a valid DNR. See page 3 for a sample of our DNR forms. They specify right on them what interventions are considered to be "resuscitation."

http://www.ambulance-transition.com/pdf_documents/training_bulletin_108_v1_dnr_standard.pdf

 

[Epi-do]

I'm curious then because that's not what the Indiana prehospital DNR form states.

It's per our protocol:

DETERMINING THE NEED FOR RESUSCITATION

...

B. Do Not Resuscitate (DNR) orders:

1. If health care personnel or family members are present at the scene of a patient in cardiopulmonary arrest and request that resuscitative measures be withheld, request to see a DNR order that has been signed by the attending physician. If presented, resuscitative efforts should not be initiated or may be terminated.

2. In the event the family or health care personnel cannot produce this document immediately, begin resuscitative efforts in accordance with the appropriate protocol and transport.

3. If there is any question regarding the validity of the written order, resuscitative measures should be initiated. Contact the receiving facility for further orders.

These guidelines do not apply to a Living Will.

No where else in our protocols are DNRs addressed. Granted, we can always call the hospital and talk to the doc if we have a respiratory arrest patient that has a DNR and family is adament we do not do anything. Then it comes down to how well you can paint a picture for the doc on the other end of the radio.

If you get a baby (as in "new", not pediatric/neonate) doc on the other end it is a complete crap shoot whether or not they would let you not do anything. Most of them are going to play it safe and have you do what you can. If you get one of the docs that have been around for a while and give a good report you are most likely going to be granted your request to honor the DNR.

 

[BossyCow]

This is why our state went from a DNR to a POLST. Physician's Orders on Life Sustaining Treatment. This document outlines what is an what is not acceptable treatment in specific situations.

 

[lightsandsirens5]

Here is Washingtons POLST form. LIke BossyCow said, it has more detailed info ref. what to do and not to do.

http://www.wsma.org/files/Downloads/PatientResources/polst_form.pdf

It can get a little confusing though. I went on a code once and the family told us that the pt had a DNR. Well, my partner saw the POLST on the back of the door and the pt had the CPR/Attempt Resuscitation box and the Full Treatment box both checked. :wacko:

 

[MSDeltaFlt]

If a patient has a valid DNR, and they are having inadequate breathing, does the DNR apply to lets say bagging them? How bout not breathing? Does DNR only apply to CPR/Shocking interventions?


I have a difficult partner that thinks she knows everything and was wondering what the correct answer is

This is why our state went from a DNR to a POLST. Physician's Orders on Life Sustaining Treatment. This document outlines what is an what is not acceptable treatment in specific situations.

With this country being as litigation happy as it is, Bossy's protocol seems a very safe way to go, unfortunately. DNR's were meant to let those who are dying to go ahead and die in peace. So check your state and local guidelines first.

Around here? If they stop breathing, we won't bag 'em. If they don't have a blood pressure, we won't give them one (Dopamine, pacing, etc). If they lose a pulse, we won't generate one. So long as they have a valid DNR copy to give us. Translation: if they're dying, we let them die. Around here resuscitation is considered life support. The forementioned are considered life support.

However, if they're short of breath, having chest pain, nausea/vomiting, diarrhea, or anything else, we treat it.

Get the point?

 

[Epi-do]

Here is Washingtons POLST form. LIke BossyCow said, it has more detailed info ref. what to do and not to do.

http://www.wsma.org/files/Downloads/PatientResources/polst_form.pdf

It can get a little confusing though. I went on a code once and the family told us that the pt had a DNR. Well, my partner saw the POLST on the back of the door and the pt had the CPR/Attempt Resuscitation box and the Full Treatment box both checked. :wacko:

That definately spells things out without as much grey area as a DNR, especially when the family is telling you contradictory things from one member to the other, or compared to the DNR. I have also come across families that don't understand a living will is different than a DNR and we cannot honor a living will. In certain circumstances though, I have heard of docs granting online orders to EMS onscene regarding details specified in a living will.

 

[lightsandsirens5]

That definately spells things out without as much grey area as a DNR, especially when the family is telling you contradictory things from one member to the other, or compared to the DNR. I have also come across families that don't understand a living will is different than a DNR and we cannot honor a living will. In certain circumstances though, I have heard of docs granting online orders to EMS onscene regarding details specified in a living will.

Yep. Leading the way in EMS here in the Peoples Republic of Washington.

(Just kidding of course.)

 

[ffemt8978]

That definately spells things out without as much grey area as a DNR, especially when the family is telling you contradictory things from one member to the other, or compared to the DNR. I have also come across families that don't understand a living will is different than a DNR and we cannot honor a living will. In certain circumstances though, I have heard of docs granting online orders to EMS onscene regarding details specified in a living will.

And family on scene can override a POLST...which is why we always call Med Control in situations like that. Let the guy with all of the education hang it out there for the lawyers to take shots at.

 

[medic417]

And family on scene can override a POLST...which is why we always call Med Control in situations like that. Let the guy with all of the education hang it out there for the lawyers to take shots at.

Med control is not an option for some of us, so we have to decide.

 

[ffemt8978]

Med control is not an option for some of us, so we have to decide.

Huh? What do you mean med control is not an option?

 

[JPINFV]

Not every place has online medical control.

 

[ffemt8978]

Not every place has online medical control.

Even so, can't you call the receiving facility and speak to the ER doc?

 

[JPINFV]

Nope. When I worked in So Cal we sent our entry note to dispatch (age, sex, PMD, CC, anything direly important [normally nothing]) and dispatch called the hospital. It wasn't until I started working in MA that I actually called the hospital direct for anything.