dnr

Hunter

Hunter

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So I got into a discussion with one of my supervisors and a co worker of mine recently about a patient of mine who had a DNR (Do Not resuscitate) order.

The patient presented with severe hypotension, going to the hospital for acute onset AMS, lethargy & confusion. The medic who had this call started an IV on the patient, administered fluids on the way to the hospital, did a 4 and 12 lead, glucose, ect. full assessment in which everything came out normal, except for the BP.

The whole argument started when the supervisor said that because the patient has a DNR we don't start IV's or administer any type of ALS treatment. The medics argument is that while if the patient codes he won't try to bring them back, as it is an order to not bring back the patient once they're dead. However he will treat their signs and symptoms because it is not an order to not treat their current condition, ie. administer d50 for hypoglycemic patients, fluid's for hypotensive, Zofran for n&v, ect. So I'm wondering what you guys think about DNR patients and how you would handle a call like this?
 
I agree with your partner. DNR doesn't mean watch them die. They still get full comfort measures. If they're hypotensive, altered, and dehydrated, I'll be giving them fluids.
 
A dnr is just that. You can do whatever you want to help their condition unless the condition requires resuscitation.
 
dnr does not = do not treat.... unless they die
 
Medic Tim said:
dnr does not = do not treat.... unless they die
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No tube no compressions no shock. The DNR usually specifies exactly what you cannot do. Some people even choose to just do no compressions but full respiratory. If my DNR grandmother was hypoglycemic and you did not give her d50 because of the DNR and she died i would sue you and win.
 
Don't really have much to say other then the medic was right. You still treat the patient. If they go into cardiac arrest then you don't do anything.

Yesterday we had a 80 Y/O female who was in SVT with a DNR. We still treated her and transported.
 
I've met so many providers who have the mentality that a dnr means to not treat. More legal education needs to be given to providers.
 
I think the thing to keep in mind is:

Are you treating a reversible condition?

People usually have a DNR for some type of terminal illness. (other than stupidity, which is a terminal disease too) Cancer, renal failure, end stage CHF, et al.

DNRs are entitled to comfort care, pain control, sedation, control of vomiting, etc.

If the chief complaint of the day is a reversible illness and not a terminal event of the disease process that invoked the DNR, then treatment is absolutely indicated.

As mentioned, some DNRs even specify what if any measures are to be taken. I have seen some really weird and/or pointless requests.

Bottom line, medic was right.
 
PoeticInjustice said:
I agree with your partner. DNR doesn't mean watch them die. They still get full comfort measures. If they're hypotensive, altered, and dehydrated, I'll be giving them fluids.
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Just to go off this, while DNR, like others have mentioned, refers to do not resuscitate i.e. no intubation and no chest compressions, keep in mind you may run into "comfort measures only" (CMO) terminology which basically is a step further where the only goal is controlling pain/suffering. Practically it's usually in the last stages where we may only be giving pain meds and benzos for comfort. Usually that does not involve fluids.

So for a DNR patient, yea I'm going to do everything including aggressive treatment up to the point of intubation or coding. But fluid resuscitation, pressors, Abx, invasive procedures, etc are still on the table if the patient and/or family desire.
 
A DNR order only applies in Cardiac Arrest situations.

A POLST (Physician's Orders for Life Sustaining Treatment) would cover what treatments the patient deems they want. Usually, if someone has a chronic or terminal condition and a POLST they will also have a do not transfer order. I've never run across a POLST in EMS so I dont know how I would handle it. I would probably stay away from any interventions in it. It also helps than my transport times are generally less than 10 minutes
 
One thing to remember is that advance directives (I'm not going to get nitpicky with POLST vs DNR vs ____) will include a bunch of options on various treatments like NG tubes, IV fluids, antibiotics, etc. If an advanced directive is in play where the patient declines IV fluids, then your hands are tied unless the patient revokes the directive.
 
Hunter said:
So I got into a discussion with one of my supervisors and a co worker of mine recently about a patient of mine who had a DNR (Do Not resuscitate) order.

The patient presented with severe hypotension, going to the hospital for acute onset AMS, lethargy & confusion. The medic who had this call started an IV on the patient, administered fluids on the way to the hospital, did a 4 and 12 lead, glucose, ect. full assessment in which everything came out normal, except for the BP.

The whole argument started when the supervisor said that because the patient has a DNR we don't start IV's or administer any type of ALS treatment. The medics argument is that while if the patient codes he won't try to bring them back, as it is an order to not bring back the patient once they're dead. However he will treat their signs and symptoms because it is not an order to not treat their current condition, ie. administer d50 for hypoglycemic patients, fluid's for hypotensive, Zofran for n&v, ect. So I'm wondering what you guys think about DNR patients and how you would handle a call like this?
Click to expand...

If it was strictly a DNR, then yes, you would treat.

If it was a POLST form you would follow what level of care they had selected. If comfort/palliative care was the level of care they selected then administering fluids for hypotension is generally a violation of their POLST.
 
A tricky situation. Here its a bit of a grey area with guidance describing it inappropriate to administer life-prolonging treatments such as IV fluid, artificial ventilation or CPR but that it is appropriate to relief symptoms of anxiety and distress e.g. pain relief, ondansetron, oxygen or salbutamol.

The term DNR is being replaced with AND (allow natural death) as it is more useful and clear than DNR which has traditionally only thought to be useful for cardiac arrest when apparently this was not the case.

If I faced such a uation and the patient was not at the very end of their life I would probably seek advice from the family or palliative care team but if she had an AND instead of a DNR I would be hesitant to provide such treatment, especially if the patient was at the very end of life.
 
94H said:
A DNR order only applies in Cardiac Arrest situations.
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No. Well, strictly speaking as death is heralded by asystole , then yeah sort of. If by "Cardiac Arrest" you mean "heart attack", then definitely no.

HOWEVER, as with any medico-legal document, the wording has to make legal and medical sense.
 
FL DNR states "No Intubation, no Defib, no CPR in cardiac arrest." in much more legal terms.

I'm glad to see however that I'm not the only one who would've treated the patient's S & S. It's funny though because a month before that we had another DNR patient who we pushed D50 and the Operations manager called us to tell us good job.
 
Hunter said:
So I got into a discussion with one of my supervisors and a co worker of mine recently about a patient of mine who had a DNR (Do Not resuscitate) order.

The patient presented with severe hypotension, going to the hospital for acute onset AMS, lethargy & confusion. The medic who had this call started an IV on the patient, administered fluids on the way to the hospital, did a 4 and 12 lead, glucose, ect. full assessment in which everything came out normal, except for the BP.

The whole argument started when the supervisor said that because the patient has a DNR we don't start IV's or administer any type of ALS treatment. The medics argument is that while if the patient codes he won't try to bring them back, as it is an order to not bring back the patient once they're dead. However he will treat their signs and symptoms because it is not an order to not treat their current condition, ie. administer d50 for hypoglycemic patients, fluid's for hypotensive, Zofran for n&v, ect. So I'm wondering what you guys think about DNR patients and how you would handle a call like this?
Click to expand...


Your supervisor needs to read up on DNR's. A DNR does not mean we don't care for the patient. Comfort care measures still take place. Most DNR's specify what is to be done or not done. The common ones I see are No CPR only. Everything else is a go.
 
leoemt said:
Your supervisor needs to read up on DNR's. A DNR does not mean we don't care for the patient. Comfort care measures still take place. Most DNR's specify what is to be done or not done. The common ones I see are No CPR only. Everything else is a go.
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I will admit that the POLST forms WA state uses makes this a lot easier than just a DNR.
 
ffemt8978 said:
I will admit that the POLST forms WA state uses makes this a lot easier than just a DNR.
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Amen! Delaware just went to a MOLST form, but it's not widespread yet. I still come across DRN orders written on a prescription pad sheet. :(
 
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