Honoring a DNR

[Eric_Milam]

I need soem clarification regarding DNR's. I know that EMT-B cannot pronounce death. Are we required to honor the DNR. In my situation we dont have medics. We are a BLS transport company with to Basics on board. There is a buzz goig round the county that basics cannot pronoounce so they cannot honor a DNR that would be failure to act. The CA protocols dont go into details, but alway refer to having a medic on board, or a Dr. and old protocols even state having two intermediates. Anyone who can shed some light would be helpful

 

[MMiz]

Welcome to EMTLife!

What do your county protocols says? Ours are very clear in this situation, and EMT-Basics can pronounce a patient dead. What about during a decapitation or rigor mortis, you're telling me that you have to work the patient all the way to the hospital?

I'm going to assume your county protocols have very detailed information on the situation. You may want to refer to those first.

 

[medicdan]

From what I understand, only a Medical Examiner can sign a death certificate. We can assume (and not treat) death in a few cases that include:
-Rigor Mortis
-Decapitation or severed trunk
-Seeing significant brain matter
-Highly significant blood loss
-Decomposing tissue

I think there are several more but I am blanking on them now... But in all other cases, we NEED to resucitate and transport to an ER. In cases above, we can call the Medical Examiner (but I dont think we can leave the scene until the ME arrives= higher qualifications..?)

In terms of DNR-- MA has a set of laws on the books called Comfort Care-- a pt can, with their MD sign a document that is a DNR. The PT is required to wear a bracelet and have the original document in easy access. If we dont find the bracelet AND the document, we need to resucitate.

 

[Ridryder911]

It is all dependent on local and state policies and laws. EMT's may not pronounce but they can declare death. Do Not Resuscitation (DNR) & Living Wills are both legal documents and authorization. Legally, if one does perform resuscitation upon one that does have such orders they technically can be going against a legal wishes.

DNR has to valid according to local laws and should be up dated and honored if valid. This is the reason they were established to begin with. Remember DNTR and Living Wills are NOT the same and should be honored differently. Living Wills are legal document as well, that actually describe the choice of care (or lack of) and extent of care that is addressed. Such as no IV's or intubation and being placed on ventilator, etc..


Remember, DNR ONLY means AFTER they have arrested no care is performed to resuscitate, not to prevent an arrest or restrict care.

R/r 911

 

[KEVD18]

The PT is required to wear a bracelet and have the original document in easy access. If we dont find the bracelet AND the document, we need to resucitate.

you only need one or the other, bracelet or form. either must be original, or a photocopy if you have seen the original. ex, a dislysis pt i take carries with he a xerox of her dnr. i can legally accept that in the field because, hanging on the wall in her kitchen is the original

you cant pronounce death in this state. medics cant pronounce either. all you can do( or not do depending on view point) is not work the code. in those circ(rigor, pml, decap etc). the me still needs to pronounce.

with one of those situations, or a valid dnr, its not abandonment or failure to tx. its following protocols

 

[TKO]

yeah, what Rid said.

What does pronouncing death have to do with a DNR? It's essentially just a no CPR-Defibrillation order (usually). Some will say allow AR but not compressions, etc. You just need to obey their wishes if the situation arises.

If you could pronounce death, then there would be no need to attempt to resuscitate, would there? "Ok, I'm calling it. Death at 3:53 AM. BEGIN CPR!!!" LMAO!

Remember that a DNR must be signed and dated. If they are not, they are invalid. And a patient/facility must show it to you when you take care of them otherwise it doesn't exist. I have had nurses tell me not to worry, there is a DNR. I tell them there sure isn't until I see it. We all have rules we have to follow and their laziness is not an excuse to be pissy at me because I'm trying to do my job. Besides, clerical and drug errors are not uncommon and if you do not resuscitate because a nurse told you there was a DNR and it turns out there wasn't or there were stipulations you didn't see -- that nurse won't even pretend to know you, and you are completely responsible for killing your pt.

Learn what you need to know about DNRs! Start asking the higher-ups for more info and see to it that everyone in your service knows about it. This sounds like it could turn into an ugly situation if not looked after. I have heard some stupid things in my short time; I knew a crew in a transfer company that thought that the DNR meant doing absolutely nothing (in this case, their pt was having difficulty maintaining her airway and they withheld suction because they thought that would interfere with the DNR). I sorted those boys out, let me tell you.

 

[Epi-do]

As already stated, it really depends upon where you are at, what the local laws are, etc.

Here, a basic is allowed to determine CPR should not be started under certain circumstances (decapitation, transection, rigor mortis, livor mortis, etc) or if a valid DNR is presented to the crew. Per our medical director, we cannot honor a "pick-n-choose" DNR on the street. It must be all or nothing. Therefore, if the DNR says "chemical resuscitation only" it is the same as them not having a DNR for us. The only way we can get around this is to call the hospital and request orders to terminate.

Our medical director has also told us that if the family presents a living will, we have to ask if there is also a DNR order. Without the DNR, we cannot honor the living will, even if it states "no cpr". Again, we can call the hospital and talk to a doc to request orders to terminate resuscitative measures, but it is at the docs discretion.

 

[BossyCow]

you only need one or the other, bracelet or form. either must be original, or a photocopy if you have seen the original.

This depends on the locality. We need to see the actual, signed, witnessed document. I've been on calls where either the document has been signed, we've seen it in the past, and husband has ditched it and is saying.. "Do everything!" and the one where patient re-did the document and family/caregiver is saying the older document is the most current.

In Washington state it's called a P.O.L.S.T Physician's Orders On Life Sustaining Treatment and covers more than just CPR. It's pretty detailed. You can give 'comfort measures' pain killers, water, O2 for comfort, nitro for chest pain, or you must do everything.

Check with your local MPD and see what your local protocols say about this.

 

[FF/EMT Sam]

I need soem clarification regarding DNR's. I know that EMT-B cannot pronounce death. Are we required to honor the DNR. In my situation we dont have medics. We are a BLS transport company with to Basics on board. There is a buzz goig round the county that basics cannot pronoounce so they cannot honor a DNR that would be failure to act. The CA protocols dont go into details, but alway refer to having a medic on board, or a Dr. and old protocols even state having two intermediates. Anyone who can shed some light would be helpful

This is such a broad issue that you really need to ask someone familiar with your local protocols. All that we can give you are guesstimates and our local protocols, which may differ wildly from yours.

That said, when in doubt, do everything that you can for a patient. It is much better do have to defend yourself for doing CPR and defibulation than to have to defend yourself for watching and doing nothing while a patient died.

 

[KEVD18]

thanks for the insight into your protocols. i was only referencing ma rules, but it is interesting to see what its like everywhere else

 

[TKO]

yes. Always consult local guidelines and protocols. That's good advice no matter how many times you hear it.

But as I was trying to get across, don't wait until your pt is pronounced dead to act, because I guarantee you that it is too late.

"Aaaand the rhythm is asystole. Finally! ok, CLEEEEEAR!!"

 

[medicdan]

Local Protocols

Sorry-- If you were asking about MA protocols-- this is the best place to check

http://www.mass.gov/?pageID=eohhs2s...+(DNR)+Order+Verification+Program&sid=Eeohhs2

Enjoy!

 

[KEVD18]

Sorry-- If you were asking about MA protocols-- this is the best place to check

http://www.mass.gov/?pageID=eohhs2s...+(DNR)+Order+Verification+Program&sid=Eeohhs2

Enjoy!

i dont know if reading thast is something someone would enjoy....

just out of curiosity, where are you attending school. i work and teach in the boston area. anything you might be confused on regarding local protocols, feel free to pm me and i'll do my best to shoot your in the right direction.

 

[adcantu]

what about dnr tattoos? I know of two cases where people had tattood on their chests DNR...

So you find this old lady (both these cases I believe the women were in thier 80s), take off her blouse, and find these tattoos! what do you do!? well if I were in that situation, I would check her purse or wallet, or her person for any indication of an actual dnr... without that, I would go through treatment lol. A tattoo while clearly stating the pt's wishes, in court I dont think it would hold up. Kind of a tricky ethical / legal sitation to be in eh?

 

[Ridryder911]

Tatto's are not legal binding statements...thank goodness! I know of several that have the "DNR" tatts. They are considered only a expression of art and expression.

R/r 911

 

[firecoins]

Tatto's are not legal binding statements...thank goodness! I know of several that have the "DNR" tatts. They are considered only a expression of art and expression.

R/r 911

yeah, your forced to have a tattoo your whole life. Hopfully not in all death as well.

 

[Raf]

you only need one or the other, bracelet or form. either must be original, or a photocopy if you have seen the original. ex, a dislysis pt i take carries with he a xerox of her dnr. i can legally accept that in the field because, hanging on the wall in her kitchen is the original

you cant pronounce death in this state. medics cant pronounce either. all you can do( or not do depending on view point) is not work the code. in those circ(rigor, pml, decap etc). the me still needs to pronounce.

with one of those situations, or a valid dnr, its not abandonment or failure to tx. its following protocols

From what I've heard in Mass, this is not true. The friends, family, etc of the patient must be able to present the document to you and patient must be wearing matching bracelet. It's both, or you're getting rescuscitated by me.

Again check with local protocols! Anything we say here is meaningless when compared to the law.

 

[KEVD18]

http://www.mass.gov/Eeohhs2/docs/dph/emergency_services/comfort_care_form.pdf

above is a link to the mass oems cc/dnr form. unfortunatley, i cant get a graphic of the back where it outline the protocol of accepting it. take my word for it, it states that while wearing of the bracelet is prefferable, it is optional. on the actual braclet insert at the bottom of the form above, you may note that it does say "if used". if not used they are to be destoryed.

the form, or the bracelet, individually serve as the order. you need only one, in the original form. you may also use a photocopy for transport, such a dr appt if you have personally seen the original that day.

without going into detail, i ahve been involved in legal proceeding regarding mass oems comfort care protocols and the honoring of a dnr.

 

[KEVD18]

oh yeah, you also have too make every effort to identify the pt(hence why me like the bracelet). if a family member says " i called. its my dad, over there on the floor" thats a reasonable identification

and if you ever decided to work a code with a valid dnr order in front of you, god help you brother cause your screwed.

 

[BossyCow]

oh yeah, you also have too make every effort to identify the pt(hence why me like the bracelet). if a family member says " i called. its my dad, over there on the floor" thats a reasonable identification

and if you ever decided to work a code with a valid dnr order in front of you, god help you brother cause your screwed.

I think I'd rather be explaining why I did than why I didn't.