Out of hospital DNR question

Fezman92

Fezman92

NJ and PA EMT
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So naturally I do a lot of transports of elderly PTs with a variety of medical issues and usually there's an out of hospital DNR, but most of the time, there's no PT signature. Just the doctor. Why do I keep seeing out of hospital DNRs that aren't signed by the PT or a designated caregiver/someone who has power of attorney?
 
Fezman92 said:
So naturally I do a lot of transports of elderly PTs with a variety of medical issues and usually there's an out of hospital DNR, but most of the time, there's no PT signature. Just the doctor. Why do I keep seeing out of hospital DNRs that aren't signed by the PT or a designated caregiver/someone who has power of attorney?
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Are these from healthcare facilities like nursing homes? It's very common for them to incorrectly complete the paperwork.

Around my parts, it's rare to see the doctors signature. I politely hand it back to the staff and tell them "this is invalid. He/she is a full code." It happens a lot Unfortunately.
 
From hospitals to nursing homes. I had one that was signed by the PT, but not the doctor so we waited for the doctor to sign it. When I asked my supervisor about what to do with them if a PT goes into cardiac arrest I was told to treat it like a full code. Luckily I haven’t had to deal with that situation yet.
 
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In PA, the PHYSICIAN issues an out-of-hospital DNR.
When Order is Effective: An out-of-hospital do-not-resuscitate (DNR) order is effective when it is signed by the attending physician. The attending physician signs last. It remains in effect until the death of the patient or the order is revoked.


What if there is a question about the validity of an out-of-hospital DNR order at the time of cardiac or respiratory arrest?
If an EMS provider is uncertain regarding the validity or applicability of the out-of-hospital DNR order, bracelet or necklace, the provider will administer CPR in the event of a person’s cardiac or respiratory arrest unless the medical command physician under whose direction the provider functions directs the withholding of CPR. That physician will ask the provider to explain the reason for uncertainty. Based upon the information provided, the medical command physician will make a good faith assessment of whether the described circumstances constitute a revocation, and then direct the EMS provider to withdraw or continue CPR based upon that assessment. However, if the EMS provider is uncertain regarding the validity of an out-of-hospital DNR order, the EMS provider may begin providing CPR before contacting the physician
 
NomadicMedic said:
In PA, the PHYSICIAN issues an out-of-hospital DNR.
When Order is Effective: An out-of-hospital do-not-resuscitate (DNR) order is effective when it is signed by the attending physician. The attending physician signs last. It remains in effect until the death of the patient or the order is revoked.
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Your post is a little misleading, I think. The physician issues the order, but the patient (or appreciate surrogate) must also sign the form.
 
NPO said:
but the patient (or appreciate surrogate) must also sign the form.
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Yeah and the problem is that just about none are signed, so I just ignore them. I just don't get why even if they're going back to a residence (not a nursing facility), they aren't signed by the PT or a surrogate.
 
NPO said:
Your post is a little misleading, I think. The physician issues the order, but the patient (or appreciate surrogate) must also sign the form.
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You're right. I stand corrected.

Review of order before signing. Before completing, signing and dating an out-of-hospital DNR order, a patient’s attending physician shall ensure that the patient is identified in the order, that all other provisions of the order have been completed, and that the patient or the patient’s surrogate, as applicable, has signed the order.

28 Pa. Code Chapter 1051. Out-Of-Hospital Do-Not-Recuscitate Orders

Information included at this site has been derived directly from the Pennsylvania Code, the Commonwealth's official publication of rules and regulations and from the Pennsylvania Bulletin, the Commonwealth's official gazette for information and rulemaking
www.pacodeandbulletin.gov
 
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Part of our job is making sure the forms are properly filled out. Of its not, make sure the sending facility staff/family/whoever knows full well the form is invalid if incomplete and you will have to treat them as a full code.

Sometimes, especially at nursing homes, that's about the most you can do.

I remember one time, years and years ago now, we were sent to a hospital to pick up a patient going to home hospice. Of course when we got there they had an incomplete DNR, and we informed the hospital staff. It was one of those small, "band aide box" type places, the Doc who had set up the transfer had gone off duty already, but the current Doc on duty knew about the case.

Rather than just rubber stamp a new form, he went into the patient's room to have the standard talk about signing a DNR. That turned into like an hour long conversation. Apparently the patient wasn't too thrilled about hospice in the first place and in that conversation, changed their minds and decided they wanted to fight whatever advanced cancer it was they had (I forget exactly).
So we ended up driving back to our base with no patient transport, our company was not too happy, but hey, we ended up serving as a patient advocate by recognizing the incomplete DNR and getting that conversation going.
 
Jim37F said:
Apparently the patient wasn't too thrilled about hospice in the first place and in that conversation, changed their minds and decided they wanted to fight whatever advanced cancer it was they had (I forget exactly).
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Wow
 
Remember DNR's vary state to state: some states you just need patient or Power of attorney signature some you just need doctor signature, some both, I have heard of a couple that need 2 doctors signatures.


Jim37F, sounds like what I have ran into a few times in the past.

Fezman, better than taking a patient home from an ECF to die on Hospice, and during the transport while digging through the 2 reams of paper (literally 294 pages of paper) I found the DNR that wasn't signed by the doctor and pointed it out to the patient that it wasn't valid: He stated he hoped for my sake that we got home before he died, because "I don't feel well".
When we got him home, he told his wife and kids the problem with the paperwork, and he took his last breath while we were moving him from our cot to the bed: Hospice care hadn't made it to the house yet, so I called the ED that he normally went to and talked to the doctor real quick while my partner put the monitor on. Doctor was cool and told us not to work him. When I asked him for his name and he responded 'Doctor Blank' I almost yelled at him on the phone.
Went by the hospital to get a look at his ID (Charge nurse gave me a copy of his ID: they had a few of them at the desk, I guess they ran into the problem before, his name was actually Dr. Blanck. LOL.

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