DNR/STEMI/Defib?

cruiseforever

cruiseforever

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Took a pt. to the cath. lab that was a DNR pt. I asked the Dr. what they would do if the pt. arrested while having the artery opened? He said since it was their treatment that caused the arrest, they would defib. the pt. once and then more than likely call the code. He did say they have a conservation with pt. and family about their choices before the angiogram.

What would you do if you picked up a pt. that has a DNR, presents as a STEMI, and they arrest while being transported?

Had a talk with my medical director and he advised that once a diagnosis of a STEMI is made. I should explain to the pt. the possibility of cardiac arrest and the treatment involved and to honor the pt.'s wishes.
 
If they have a valid DNR, it doesn't mean "sometimes you can resuscitate". It means DO NOT resuscitate.

Following the DNR directive is honoring the PT's wishes.
 
If you're going to bother taking a DNR patient to the cath lab (one imagines after consent from the patient or family) then it makes sense to defibrillate if the patient experiences VF during the procedure. It's a common thing that happens especially when reperfusing the RCA. That's a different scenario than a DNR patient who goes into VF/pulseless VT during transport. If you think the patient is in extremis and has the present mental capacity to make informed decisions then ask them to weigh in before they code. Otherwise accept that everybody dies. VF/VT is not a bad way to go! Much better than broken ribs and a tube shoved in your gullet, that's for sure.
 
It's very common in hospitals for DNRs to be rescinded during surgeries or major procedures. My hospital even includes a yes/no checkbox to cover those situations on the in-hospital DNRs.
 
you're presenting 2 different scenarios. in the first, if the doc talked with the patient and he/she wants x, y, z....then thats what you do.
if a dnr pt codes en route to the hospital then...its comfort measures only, unless of course the pt then tells you he/she wants everything done then you honor their wishes.
 
cruiseforever said:
Took a pt. to the cath. lab that was a DNR pt. I asked the Dr. what they would do if the pt. arrested while having the artery opened? He said since it was their treatment that caused the arrest, they would defib. the pt. once and then more than likely call the code. He did say they have a conservation with pt. and family about their choices before the angiogram.

What would you do if you picked up a pt. that has a DNR, presents as a STEMI, and they arrest while being transported?

Had a talk with my medical director and he advised that once a diagnosis of a STEMI is made. I should explain to the pt. the possibility of cardiac arrest and the treatment involved and to honor the pt.'s wishes.
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Honor their DNR unless they had rescinded. These are two entirely different scenarios.
 
maybe the bigger question is, why would a patient with a DNR go to the cath lab? And yes, if the patient went into a VF during the procedure, I could see a different relationship would be indicated. But during transport?

And at the end of the day, every death is eventually the result of cardiac arrest. A cath on a patient with a DNR, assuming that they had a DNR due to a terminal illness, and then expecting the transporting EMS agency to perform a resustation if needed seems like an ethical conundrum.
 
STEMI pt with a DNR who codes on the way to the cath lab? Depending on the circumstance we might shock a VF or VT, but I'm certainly not starting CPR.

Not all DNRs are created equal. I'd definitely take a DNR pt to the cath lab if their DNR was strictly a "No CPR" order. Other patients will have DNRs with specific orders such as no invasive procedures and no IV meds, comfort measures only; that pt I would probably not activate the cath lab after consulting the Doc.
 
"Sir you are having a heart attack. If I don't do anything your heart will stop and you will die. I know you have a DNR and I just want to let you know what is happening. Just so we are clear, if your heart stops you do not want me to do anything is that correct?"

and then:

"if your heart stops, I can try to shock it back into beating again, and I can do CPR. Just so we are on the same page, you do not want me to do either of those right?"

Its basically informed consent, except backwards.
 
That's the beauty of the POLST form. Takes the guesswork out of this and spells out exactly what they want
 
DrankTheKoolaid said:
That's the beauty of the POLST form. Takes the guesswork out of this and spells out exactly what they want
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I was very happy when NV began using POLST forms and allowing us to accept them as a prehospital DNR. Before that all we could honor without OLMC was the state-issued prehospital DNR that's an absolute PITA to get and takes a while to process which isn't always a luxury some patients have.

Just because a PT has a DNR doesn't mean that they have a horrifically poor quality of life. More than a few patients live for extended periods of time and have to renew their DNR, if they have a decent quality of life why should they not be offered a treatment which is ultimately minimally invasive and that many patients are discharged from the hospital within the week after undergoing the procedure.

I wouldn't advocate going to town on them if they arrest but with their consent I see no reason not to take the PT to the lab and shock a witnessed VF/VT arrest.
 
TomB said:
Otherwise accept that everybody dies. VF/VT is not a bad way to go! Much better than broken ribs and a tube shoved in your gullet, that's for sure.
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I have no issues with people dying. Just seeing more people that have DNRs living productive lives. I've gotten into the habit that if the person has a DNR and is in control of their health care to ask them about it. As someone else said the POLST form is giving pts. a better form to make their wishes known.
 
Angel said:
you're presenting 2 different scenarios. in the first, if the doc talked with the patient and he/she wants x, y, z....then thats what you do.
if a dnr pt codes en route to the hospital then...its comfort measures only, unless of course the pt then tells you he/she wants everything done then you honor their wishes.
Click to expand...

In our area if the person is a DNR pt. only. They are suppose to recieve aggressive treatment up to the point of cardiac arrest. Hospice is comfort measures only for us.

Yes they are two diffrent scenarios. One just led me into another.
 
DNRs only matter for natural causes. If they're shot, you do CPR. If they arrest because of treatment you did, you do CPR.


If they arrest from a STEMI during transport, you honor the DNR.
 
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