Honoring a DNR

paramedics can pronounce death but the ME has to declare it and sign the paperwork. emt basics can still only do nothing. my suggestion is if your looking for more responsibility be a medic.
 
I've been an EMT for 22 years in Los Angeles. The EMS agency issued a policy regarding DNR's and the company did the same.

Basically, a DNR patient belongs at the facility of choice whether that's a hospital, extended care facility or residence (the last two refer to discharges from the hospital).

Whenever I transport a patient I always ask the patient's code status and check the transfer paperwork to confirm what the nurse tells me, and if the patient is going home then I'll ask to see the DNR order before we leave the facility.

When you transport these patients you provide comfort measures which can include positioning of the patient, oxygen and suctioning to maintain their airway.

If the patient dies in your care then confirm the death and note the time on your paperwork.

We had this happen to both my partner and myself recently. In the case of my patient, we were transporting to an extended care facility and she died about 10 minutes before arriving at the facility.
On arrival my partner went inside the facility to let them know what happened, then we took the patient inside and left her in a private room.

In the second case we transported from an extended care facility to the emergency room, and shortly after arriving (in the presence of the nursing staff and the ER MD the patient died.

As EMT's all we can do is confirm a DNR order is in place, and if the patient stops breathing then note the time in your paperwork, and if there is no DNR then work up the patient and divert to the closest ER.
 
Eric_Milam said:
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
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as long as you have the DNR WITH YOU ! signed by a physician then yes you have to honner it.
 
You actually have to have the DNR in hand. if someone says that they have a dnr.... by law you have to resucitate until they get that dnr in hand. no ifs ands or butts about it...
 
Here in Wisconsin

they gotta have the bracelet and its got to be on.... its a problem cause in the nursing homes the caregivers like to leave them off ( guess it saves them .3 minutes during baths or something) then when you go to pick them up they bring you the bracelet on a clipboard..
sucks big time because if the patient is non responsive, how do we know if they took it off because they wanted to rescind the DNR or WHAT ?

The rule for us is if they are not wearing it then it is not a valid DNR...

that being said, we were taking in a 83 year old from hospice to hospital for pain relief... the EMT-P had pushed 40mg of morphine and the guy was still hurting...
if he had coded, we were supposed to start pounding on him ??? thank god he didnt...
 
Mercy4Angels said:
paramedics can pronounce death but the ME has to declare it and sign the paperwork. emt basics can still only do nothing. my suggestion is if your looking for more responsibility be a medic.
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Again, that's a local protocol thing

Take for instance, this memo sent out in mass 3 years ago

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

where no matter what level, unless it's obvious they're dead, they ain't dead
 
It varies by protocols... both state and regional.

In PA, we have a state DOH approved Out-Of-Hospital DNR. It involves a hospital-type bracelet as well as paperwork. Without both, it isn't legally binding for us.

If we have a DNR that is not the official Out Of Hospital DNR, we work them and consult with Medical Command. Medical Command will PROBABLY OK termination of efforts... but it is why he/she pays the big bucks for medical malpratice insurance.
 
As of January 2007 in MA: Only Comfort Care DNR's are honored. Either original or copy, or bracelet is acceptable. Only one needs to be seen.
 
Raf said:
As of January 2007 in MA: Only Comfort Care DNR's are honored. Either original or copy, or bracelet is acceptable. Only one needs to be seen.
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Comfort care DNR and DNR can be 2 very different documents. Nursing homes may have both. DNR pts will be treated in the hospital same as any other patient (and in some cases CPAP or other forms of Non invasive ventilation) up until the time of more heroic measures. Comfort care DNRs are those that are being allowed to die without intervention except pain meds, O2 and whatever the predetermined comfort will be above that. It would be important to know the type of documentation used/recognized by the State and local facilities. Hospice patients also have specific documents usually called a Comfort Care Only document that are different from other forms of DNRs. Living wills are also different documents as Ridryder911 mentioned earlier. Lots of room for confusion if you don't have clear guidelines with the different documents honored in your area.

Many physcians and for that matter patients are reluctant to have a DNR order made in fear it will be interpreted as a "Do Not Treat". Thus, that is one reason there are so many elderly people in the nursing homes without DNRs. I hear too ofter from ambulance crews and hospital staff, "they're just a DNR" or "why bother" type of care. For these reasons, my 91 y/o mother remained a full code until we put her into hospice.
 
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VentMedic said:
Comfort care DNR and DNR can be 2 very different documents. Nursing homes may have both. DNR pts will be treated in the hospital same as any other patient (and in some cases CPAP or other forms of Non invasive ventilation) up until the time of more heroic measures. Comfort care DNRs are those that are being allowed to die without intervention except pain meds, O2 and whatever the predetermined comfort will be above that. It would be important to know the type of documentation used/recognized by the State and local facilities. Hospice patients also have specific documents usually called a Comfort Care Only document that are different from other forms of DNRs. Living wills are also different documents as Ridryder911 mentioned earlier. Lots of room for confusion if you don't have clear guidelines with the different documents honored in your area.

Many physcians and for that matter patients are reluctant to have a DNR order made in fear it will be interpreted as a "Do Not Treat". Thus, that is one reason there are so many elderly people in the nursing homes without DNRs. I hear too ofter from ambulance crews and hospital staff, "they're just a DNR" or "why bother" type of care. For these reasons, my 91 y/o mother remained a full code until we put her into hospice.
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In regard to what we need to honor a DNR where I work...we can honor the written prehospital care DNR form, signed and dated (home setting) and in the case of someone that's an inpatient of a hospital or convalscent facility we can honor a written DNR order in the patient's chart.
In most cases the order will be in the transfer papers. On every transport I ask the sending nurse the patient's code status and look at the chart (and transfer papers to confirm the status) BEFORE I take the patient.

If the patient is DNR then I continue to treat the patient w/ oxygen and suction if needed. If the patient passes away during transport then we continue to the requested destination.

As I said in an earlier post this happened to me on a transport once (hospital to convalescent)...patient passed during transport so we continued to the convalescent, and when we arrived I had my partner run inside to let staff know what happened so they could find a place for the patient.

Took the patient inside the facility and into a room then gave report to the staff (nursing staff/administrator).
 
Mercy4Angels said:
paramedics can pronounce death but the ME has to declare it and sign the paperwork. emt basics can still only do nothing. my suggestion is if your looking for more responsibility be a medic.
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Ok so if the guy's head is sitting in his lap, you as an emt-b still have to call for a medic to pronounce???

doesn't sound right.

Basics in NY can pronounce providing it's obvious ( decapitation, Lividity etc.)
 
In MA an EMT-B can declare death if it's dependent lividity, decapitation, or rigor mortis. There's one more..
 
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Here it depends on the service and their protocols. A combination of the following must be present for an EMT-A to declare a death:

Rigor
Lividity
Pulseless
Apneic
Pupils F/D
Decapitation
Asystole In 3/3 Leads (We can only do 3 or 4 leads; 12 leads are for EMT-P's)
Obvious Decomp
 
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Remember your only a basic. When in doubt work the patient. And if available call for ALS or contact medical control.
 
One other note: I have heard before, in cases of SIDS, it is often in the best interest of the parents (PFA, Psycological First Aid) even if the baby is gone, we make every effort to revive the baby-- so the parents can see something was done.
 
As I understand the language on declaring death, an EMT-B can determine field death under the conditions listed above. These are generally events that occurred prior to our arrival on scene. We can tell that someone already died, but to make the determination during our care.... that requires the MPD's stamp. Unless of course, someone's head falls off while we are giving treatment! Or perhaps they suddenly experience rigor mortis.

If we show up to a live pt. unless there is a document that meets the legal requirements in effect by your protocols, and be very careful because those criteria differ widely from area to area, we must treat the patient as though they have every chance of surviving the event.
 
TraumaJunkie said:
Remember your only a basic. When in doubt work the patient. And if available call for ALS or contact medical control.
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Were you replying to my post?
 
here in mi we have protocols that state we do not have to resuscitate in cases of obvious signs of death and dnr's but we do have to call in a hern and recieve a time of death from the er doc and then call pd and they contact the me and body removal as soon as pd is on scene we are released
 
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