OK, I have a question. Here it is, and please be gentle. I am so confused about these DNR's. When called to the Nursing home is it valid? I have been told 2 things. Yes, it is and no, that it is only the facilities DNR and not something we need to respect. Also, when going to a home of a man we know has a DNR and wife has already begun CPR we continue right? even though there is a DNR order. And then one more thing we have to "see" that DNR not just take anyones word for it right? I think why call us if you don't want us to do something? :wacko:
Dnr
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PapaBear434
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It may vary from state to state, but here in Virginia we need the original version. Copies don't count, even notarized ones. We need the absolute original with a signature and notary seal on it, or we are required to work the code.
EMTinNEPA
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You withhold or stop resuscitative efforts only if a valid DNR is produced. DNRs can be voided by the POA.
ResTech
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Her question was, how does she know if it is valid?
Most States laws vary greatly when concerning DNR orders and advanced directives and can be confusing. This is why a few States have developed and signed into law DNR rules and orders specific to EMS to avoid the confusion.
Two examples, PA and MD, both have pre-hospital DNR orders. MD has a DNR "A" (maximum care) and a DNR "B" (supportive care) option. These apply to all medical facilities in MD. DNR "A" allows all care up to the point of arrest. DNR "B" only allows supportive care measures... no pharmacological agents, tubes, etc. It really helps to simplify and minimize the time it takes to decide to resuscitate when faced with a DNR order.
My best advice, check with your States EMS office or Google for DNR information specific to your home State.
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JPINFV
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Where are you? I ask because I've worked in two states and the DNR procedure was completely different.
California (Orange County protocol): EMS can accept any DNR (state prehospital or facility) signed by a physician, a written DNR order (as in written in the patient's chart) in a licensed health care facility, "Physician Orders for Life Sustaining Treatment" (POLST) forms, a "verbal" order by the patient's physician if the physician is on scene and willing to sign the PCR, and a request to withdraw or withhold by an immediate relative (adult child, adult sibling, spouse, parent, domestic partner). As well, any immediate family member can override a DNR.
Massachusetts: Only a "DNR Verification Form" is valid as a DNR. Nothing else counts.
Yes. You need to see the DNR for it to be valid. There are also very valid reasons for DNR patients to seek emergency treatment or hospitalization. DNR does not stand for "do not treat."
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paramedicmike
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If you're in doubt, pick up the phone and call your medical command doc. Explain to him/her what's going on and let him/her make the decision.
Then document the hell out of it.
That being said, knowing the procedure for your locality is important. As has been suggested, do the research into DNR policies and laws for your area and become familiar with them.
But don't forget the doc on the phone who can help with the decision making process.
Then document the hell out of it.
That being said, knowing the procedure for your locality is important. As has been suggested, do the research into DNR policies and laws for your area and become familiar with them.
But don't forget the doc on the phone who can help with the decision making process.
JPINFV
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Not everyone has the luxury of not knowing their protocols and punting to a medical control physician through online orders.
ResTech
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Its not about not knowing ur protocols and passing it off on the doc. Sometimes there is no EMS protocol for DNR. I've known of providers who had to call med command for advice or guidance on how to handle a specific arrest situation with a questionable DNR and family involvement. It's because of this that pre-hospital DNR's were created to alleviate the gray areas and be more direct.
JPINFV
Gadfly
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The problem I've seen is that there are a lot of providers who never actually read the protocol. There's nothing like getting in an argument on scene because someone didn't read the protocol and doesn't want to accecpt a verbal request from both the patient's daughter and husband regarding care (which was perfectly allowable).
Pudge40
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Also some states may have two different types of DNRs. PA for example has an out of hospital DNR and an in hospital DNR. The out of hospital DNR is a plastic card that is worn aorund the neck, they also have a braclet type I believe. If they show an in hospital DNR we must start or continue CPR. We can then call medical command and have permission to cease CPR. And on a side note in PA the patient and/or wife, son, daughter can revoke the DNR at any time. And the out of hospital DNR must be signed by a physian to be valid.
In any state the DNR laws may be very complicated.
WuLabsWuTecH
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Momof7 -- we might be of more help if you could tell us which state you are in.
Chelle
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She introduced herself in another thread and said she is from Iowa.
Medic744
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Im not sure how Iowa handles it but in Texas we must have a valid out of hospital DNR in hand. There are several versions that are acceptable such as a bracelet or necklace but they are to serve as only a reminder to ask for the original form. Family has no say so in revoking it on scene. If there is a doubt to the validity or any dispute regarding the order we (at my service) must immediately contact both the Medical Director and the Director of our service to resolve the conflict. In hospital DNRs are not valid and we do not honor them outside of the hospital. While working for transfer I have waited a few times in the hospital or nursing home before transporting a patient because they wanted to make sure we had a DNR that we could honor.
Our protocol states we can stop resuscitation immediately once a valid DNR is shown. You will have to find out on your own exactly what your state considers a valid DNR but it doesn't hurt to check out other states as well in case someone from out of state is visiting your area.
Our protocol also states that if 2 family members or a single POA is present and requests that we don't start a resuscitation we will do CPR only and contact med control but they usually allow us to do the field term then.
I guess I need to go do some reading to find out but I don't think a POA can overrule a DNR here unless the original doc agrees to it as well and by the time you get the doc on the phone the patient will be pretty far gone anyway.
Like was said before, if you're ever unsure get on the phone to med control. People can say what they want about not knowing your protocol but if you honestly don't know what to do med control is your lifeline. The doc on the other end would rather you ask than have you guess and be wrong because it's not only your license on the line it's his/hers too.
Our protocol also states that if 2 family members or a single POA is present and requests that we don't start a resuscitation we will do CPR only and contact med control but they usually allow us to do the field term then.
I guess I need to go do some reading to find out but I don't think a POA can overrule a DNR here unless the original doc agrees to it as well and by the time you get the doc on the phone the patient will be pretty far gone anyway.
Like was said before, if you're ever unsure get on the phone to med control. People can say what they want about not knowing your protocol but if you honestly don't know what to do med control is your lifeline. The doc on the other end would rather you ask than have you guess and be wrong because it's not only your license on the line it's his/hers too.
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Pudge40
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PA Statewide DNR Protocol
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 pregnant 3 , 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..Pennsylvania Department of Health Resuscitation 331 – BLS – Adult/Peds
Effective 11/01/08 331-1 of 3
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 pregnant 3 , 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..Pennsylvania Department of Health Resuscitation 331 – BLS – Adult/Peds
Effective 11/01/08 331-1 of 3
Pudge40
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Iowa Statewide DNR Protocol
I found this on Iowa's Department of public health's web site:
EMS OUT-Of-HOSPITAL DO-NOT-RESUSCITATE PROTOCOL
Purpose: This protocol is intended to avoid unwarranted resuscitation by emergency care providers in the out-of-hospital setting for a qualified patient. There must be a valid Out-Of-Hospital Do-Not-Resuscitate (OOH DNR) order signed by the qualified patient’s attending physician or the presence of the OOH DNR identifier indicating the existence of a valid OOH DNR order.
No resuscitation: Means withholding any medical intervention that utilizes mechanical or artificial means to sustain, restore, or supplant a spontaneous vital function, including but not limited to:
1. Chest compressions,
2. Defibrillation,
3. Esophageal/tracheal/double-lumen airway; endotracheal intubation, or
4. Emergency drugs to alter cardiac or respiratory function or otherwise sustain life.
Patient criteria: The following patients are recognized as qualified patients to receive no resuscitation:
1. The presence of the uniform OOH DNR order or uniform OOH DNR identifier, or
2. The presence of the attending physician to provide direct verbal orders for care of the patient.
The presence of a signed physician order on a form other than the uniform OOH DNR order form approved by the department may be honored if approved by the service program EMS medical director. However, the immunities provided by law apply only in the presence of the uniform OOH DNR order or uniform OOH DNR identifier. When the uniform OOH DNR order or uniform OOH DNR identifier is not present contact must be made with on-line medical control and on-line medical control must concur that no resuscitation is appropriate.
Revocation: An OOH DNR order is deemed revoked at any time that a patient, or an individual authorized to act on the patient’s behalf as listed on the OOH DNR order, is able to communicate in any manner the intent that the order be revoked. The personal wishes of family members or other individuals who are not authorized in the order to act on the patient’s behalf shall not supersede a valid OOH DNR order.
Comfort Care (©): When a patient has met the criteria for no resuscitation under the foregoing information, the emergency care provider should continue to provide that care which is intended to make the patient comfortable (a.k.a. © Comfort Care). Whether other types of care are indicated will depend upon individual circumstances for which medical control may be contacted by or through the responding ambulance service personnel.
© Comfort Care may include, but is not limited to:
1. Pain medication.
2. Fluid therapy.
3. Respiratory assistance (oxygen and suctioning).
Qualified Patient means an adult patient determined by an attending physician to be in a terminal condition for which the attending physician has issued an Out of Hospital DNR order in accordance with the law. Iowa Administrative Code 641-142.1 (144A) Definitions.
I found this on Iowa's Department of public health's web site:
EMS OUT-Of-HOSPITAL DO-NOT-RESUSCITATE PROTOCOL
Purpose: This protocol is intended to avoid unwarranted resuscitation by emergency care providers in the out-of-hospital setting for a qualified patient. There must be a valid Out-Of-Hospital Do-Not-Resuscitate (OOH DNR) order signed by the qualified patient’s attending physician or the presence of the OOH DNR identifier indicating the existence of a valid OOH DNR order.
No resuscitation: Means withholding any medical intervention that utilizes mechanical or artificial means to sustain, restore, or supplant a spontaneous vital function, including but not limited to:
1. Chest compressions,
2. Defibrillation,
3. Esophageal/tracheal/double-lumen airway; endotracheal intubation, or
4. Emergency drugs to alter cardiac or respiratory function or otherwise sustain life.
Patient criteria: The following patients are recognized as qualified patients to receive no resuscitation:
1. The presence of the uniform OOH DNR order or uniform OOH DNR identifier, or
2. The presence of the attending physician to provide direct verbal orders for care of the patient.
The presence of a signed physician order on a form other than the uniform OOH DNR order form approved by the department may be honored if approved by the service program EMS medical director. However, the immunities provided by law apply only in the presence of the uniform OOH DNR order or uniform OOH DNR identifier. When the uniform OOH DNR order or uniform OOH DNR identifier is not present contact must be made with on-line medical control and on-line medical control must concur that no resuscitation is appropriate.
Revocation: An OOH DNR order is deemed revoked at any time that a patient, or an individual authorized to act on the patient’s behalf as listed on the OOH DNR order, is able to communicate in any manner the intent that the order be revoked. The personal wishes of family members or other individuals who are not authorized in the order to act on the patient’s behalf shall not supersede a valid OOH DNR order.
Comfort Care (©): When a patient has met the criteria for no resuscitation under the foregoing information, the emergency care provider should continue to provide that care which is intended to make the patient comfortable (a.k.a. © Comfort Care). Whether other types of care are indicated will depend upon individual circumstances for which medical control may be contacted by or through the responding ambulance service personnel.
© Comfort Care may include, but is not limited to:
1. Pain medication.
2. Fluid therapy.
3. Respiratory assistance (oxygen and suctioning).
Qualified Patient means an adult patient determined by an attending physician to be in a terminal condition for which the attending physician has issued an Out of Hospital DNR order in accordance with the law. Iowa Administrative Code 641-142.1 (144A) Definitions.
Medic744
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emtfarva
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From what I have been told and was taught in school....
For MA: We need what is called a Comfort Care (MA's DNR form [CC]) which has to be completely filled out with all required signatures and dates. Our CC is all or nothing. We don't follow SNF's or Hosp's DNRs. We don't follow DNI's and we do not follow any variations.
If a SNF calls you because someone is in cardiac arrest, and they ask you to do something, then the DNR is reascended. The same when you are dispatched to a person's home with a valid DNR and anyone that starts CPR, you must continue unless you can call death per your protocols, or you get to the Hosp. If you have a Question in your mind, work the Pt and let the Doc at the Hosp make a decision.
For MA: We need what is called a Comfort Care (MA's DNR form [CC]) which has to be completely filled out with all required signatures and dates. Our CC is all or nothing. We don't follow SNF's or Hosp's DNRs. We don't follow DNI's and we do not follow any variations.
If a SNF calls you because someone is in cardiac arrest, and they ask you to do something, then the DNR is reascended. The same when you are dispatched to a person's home with a valid DNR and anyone that starts CPR, you must continue unless you can call death per your protocols, or you get to the Hosp. If you have a Question in your mind, work the Pt and let the Doc at the Hosp make a decision.
flhtci01
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Take a look at the Powerpoint file (last one), that should answer most of your questions. It will have to be unzipped.
Thanks so much for all your info. Mind boggling as it was LOL. What do you all think of this.... We have a little saying in our unit which I am sure is similar to all of yours. " no one dies on our shift " 
I guess my plan is to do CPR unless a "for real" DNR is in my hands and even then, if family is saying do it I do it right?
I guess my plan is to do CPR unless a "for real" DNR is in my hands and even then, if family is saying do it I do it right?