Some specific DNR/DNI questions

[ParamedicStudent]

Hello. Since I can't get a clear answer in person, I just have some questions regarding DNR/DNI paperwork, and multiple opinions regarding so.

1) For comfort measures that does not include IV access, and/or no treatment including IV access, is it only in the case of cardiac arrest? For example, in the case of cardiac arrest with no IV access as well as DNR/DNI, obvious one would not perform IV access. However, with comfort measures only w/o IV access, you'll be withholding it. When in the case that grandma had a fall as is in severe pain, do you establish IV access to administer pain meds, or administer meds via a different route without IV access.

2) For the stroke or STEMI patient with a DNR/DNI, will it still be a code 3 return with treatments, excluding compressions and/or intubation? Obviously, I'd refer this to my medical director. I was in this situation once, contacted base physician, and was advised full treatment without lights & sirens. But what if you were in the case that base or medical contact could not be contacted?

3) Do you accept an electronic copy of the POLST form, as opposed to the physical copy? Example, patient was outside and away from their home when they had an arrest, but family has an digital copy. Do you honor that?

Thank you.

 

[NomadicMedic]

Interesting questions. I’ll give you my experience and how I’ve handled each of these.

1) had a stage four lung cancer patient on hospice care who had a fall with a fractured hip, patient’s family demanded that I transport. The patient did not want IV access and it was noted on his DNR. I gave him some IM fentanyl.

2) I would consult with the doc, a hospice nurse and family. I have transported a DNR patient who had sudden onset of stroke symptoms. They brought the patient into the ED, ran the stroke protocol and proceeded to let the patient expire in the emergency department. The family decided “that it was her time”.

3) we do except electronic copies of a POLST form as long as it has a legible signature and is within date.

 

[johnrsemt]

The way I was taught is the DNR is for when they are actively dying; not when they break something,. But at the same time a patient can refuse an IV, even if they don't have an DNR.

1: DNR with broken leg. Treat the fx, take to the hospital, give pain medications however the patient will let you. Better than letting them lay there crying and screaming until they die from the shock. Although I have seen nursing homes do it.

2: transport. BLS crew did that for a Possible stroke, refused to call for a medic, I met them in the bay as I was getting ready to leave, and checked Blood Glucose, and gave oral glucose and the stroke was cured before the patient was in the room in the ED.

3: I gave the ED my dad's living will 2 weeks ago, from my phone by emailing pictures of it to them.

 

[Akulahawk]

1) For comfort measures that does not include IV access, and/or no treatment including IV access, is it only in the case of cardiac arrest? For example, in the case of cardiac arrest with no IV access as well as DNR/DNI, obvious one would not perform IV access. However, with comfort measures only w/o IV access, you'll be withholding it. When in the case that grandma had a fall as is in severe pain, do you establish IV access to administer pain meds, or administer meds via a different route without IV access.

In the case of the living patient with DNR/DNI/comfort care that excludes IV, you transport however the patient will allow you to and you provide pain relief through an alternative route. In the case of that same patient found in cardiac arrest, there's no need for IV access as the patient is dead and has valid orders for you NOT to even begin resus measures (or for you to stop once order has been ID'd as valid).

2) For the stroke or STEMI patient with a DNR/DNI, will it still be a code 3 return with treatments, excluding compressions and/or intubation? Obviously, I'd refer this to my medical director. I was in this situation once, contacted base physician, and was advised full treatment without lights & sirens. But what if you were in the case that base or medical contact could not be contacted?

This is where you must be VERY well informed of your system's policy. Here a stroke/STEMI with a DNR/DNI will still be transported to an appropriate receiving facility because the patient isn't dead yet and full treatment will be provided, possibly to include thrombolytics and/or surgery as these treat the problem and may return the patient to prior level of function... to expire another day or way.

3) Do you accept an electronic copy of the POLST form, as opposed to the physical copy? Example, patient was outside and away from their home when they had an arrest, but family has an digital copy. Do you honor that?

Our system, in many ways, is just approaching the mid-2000's. They want/prefer an actual physical POLST.