What would you do...

[ERDoc]

I have to agree with several previous posters. Do not resuscitate does not mean do not treat. The SVT needs to be treated. If your treatment leads to a cardiac arrest then document that the pt had a DNR, which was honored (word it a little better than that though). Your best action is to read the DNR paperwork to see what it specifically states and contact medical control. Several people have said that their DNR protocol says that they cannot cardiovert. Does this apply only to electrical cardioversion or does it include chemical cardioversion?

[Lone Star]

I have to agree with several previous posters. Do not resuscitate does not mean do not treat. The SVT needs to be treated. If your treatment leads to a cardiac arrest then document that the pt had a DNR, which was honored (word it a little better than that though). Your best action is to read the DNR paperwork to see what it specifically states and contact medical control. Several people have said that their DNR protocol says that they cannot cardiovert. Does this apply only to electrical cardioversion or does it include chemical cardioversion?

Wouldn't cardioversion, whether electrical or chemical in nature; be considered 'heroic measures'? I'm trying to grasp the differences, since the intended outcome would be the same. Is this just a matter of semantics?

It's been my understanding that DNR means DO NOT resuscitate. Isn't cardioversion considered 'resuscitation', or 'resuscitative measures'?

Like I said, I'm not trying to be 'difficult', or play the Devil's Advocate here. This is a true quest for enlightenment.

[spenac]

When the patient is still alive ( has pulse, breathing ) why would you with hold synchronized cardioversion? Different if you had pulseless electrical activity, then the DNR would stop all activity if that is what it asked for. So I would per protocol honor the DNR. Patients die on EMS frequently even if we have not injected a drug. When they have a DNR we honor it so no reason to change just because the outcome from our treatment was not what we expected.

[HERBIE1]

Wouldn't cardioversion, whether electrical or chemical in nature; be considered 'heroic measures'? I'm trying to grasp the differences, since the intended outcome would be the same. Is this just a matter of semantics?

It's been my understanding that DNR means DO NOT resuscitate. Isn't cardioversion considered 'resuscitation', or 'resuscitative measures'?

Like I said, I'm not trying to be 'difficult', or play the Devil's Advocate here. This is a true quest for enlightenment.

I guess this is about semantics, but then again, many of our medical/legal issues are exactly that.

Again, DNR is too generic. As we know, under the umbrella of advanced directives, there is a lot of latitude, and folks can be very specific about their wishes. No feeding tube, no intubation, no pressors, no CPR, no defibrillation, etc. I would also consider cardioversion a treatment, not resuscitation. The person may be very ill, but still not in cardiac arrest.

Clearly there are many variables here. Did the family and/or patient produce- or even make the crew aware of a DNR BEFORE they started their assessment and treatment, or did they produce it AFTER you started your interventions? Did they claim there was a DNR but were unable to produce it? Was there some question about the validity of the DNR? Is there a family conflict about the situation- does one family member suddenly have 2nd thoughts about the DNR when presented with the fact their loved one is actually now dying?

I had that happen to me a couple times, and was instructed to start CPR and transport, and let the hospital sort it all out.

These situations are always tough-there are too many potential gray areas. Emotions run high, and you have no idea the family dynamics and issues involved.

[tcripp]

Welcome. The problem is, in a scenario, with so many different local protocols, often times there is more than one "right" answer. What I may be able to do may contradict protocols in your area.

That's just it. I'm not looking for a right answer...which makes this exercise entertaining. The point I was making in my response was that you (I believe) were the only one to say, "I would..." whereas everyone else worte, "You should".

[Doczilla]

As the guy on the other end of the phone, I would order you to continue with resuscitation.

The patient's arrest is possibly iatrogenic in nature and potentially reversible with brief treatment. We suspend DNR orders during surgery for this reason.

DNR orders vary by individual and what treatment they had in mind. In my mind, resuscitation includes aggressive administration of iv fluids. Yet this simple measure can almost painlessly reverse a life threatening condition, and should be done as needed on patients with a DNR. Other things too; some say no anti-atrythmics in a dnr, but this case illustrates the benefit in a simple procedure that can turn the patient around and prevent death.

'zilla

[HERBIE1]

As the guy on the other end of the phone, I would order you to continue with resuscitation.

The patient's arrest is possibly iatrogenic in nature and potentially reversible with brief treatment. We suspend DNR orders during surgery for this reason.

DNR orders vary by individual and what treatment they had in mind. In my mind, resuscitation includes aggressive administration of iv fluids. Yet this simple measure can almost painlessly reverse a life threatening condition, and should be done as needed on patients with a DNR. Other things too; some say no anti-atrythmics in a dnr, but this case illustrates the benefit in a simple procedure that can turn the patient around and prevent death.

'zilla

I never thought of that, doc.

I assume this is something that needs to be preapproved by the patient, their designee as part of the surgical consent?

[Neesie]

After reading this, I agree with most of what has been said...if nothing else, I can see both sides. My opinion....discuss the treatment with your patiet (maybe I am just assuming they are conscious and alert), let them know the consequences of the treatment then ask if they want it. Ultimatley, if they are alert and oriented, they have the final say what treatment they get regardless if a DNR is present or not. We still need to get consent from the patient.

I recently went to an elderly female who was hypoglycemic and had a DNR. The daughter was pushing this DNR on us stating that her mother did not want ANY treatment. I had been to this residence (daughter lives with the patient) a few times and each time I honored the DNR...pt said she was dying and did not want us to do anything - just called so the daughter wouldn't get in trouble if she actually did die. Pt refused to come with us even though she was in severe resp distress. Turns out, those 2 times pt was suffering from pnuemonia and thankfully the daughter took my advice and too the patient to her family doc the next day.....back to the hypoglycemic incident with this pt - daughter is pushing the DNR. I explained to the patient that I wanted to give her some D50. Pt was alert enough to say no IV. However, when asked if she would be able to take oral glucose, she said she would take it. The daughter was not happy with us because we "breached" the DNR. I explained to her (as it was written on the paper) that she did not want us to recusitate her if her heart stopped...I still have to treat while she is still alive AND the pt agreed to the treatment.

[Linuss]

When the patient is still alive ( has pulse' date=' breathing ) why would you with hold synchronized cardioversion?[/quote']

As per Texas Dept of State Health, they actually defined what is NOT allowed per a legit OOH-DNR

So theoretically, you're fine pushing cardiac drugs such as Adenosine for svt as the law only states electrical cardioversion, and not chemical. So long as you aren't pumping, breathing, or shocking, you should be fine in the realm of life-saving measures.

Although my agency's protocols specifically state no "Cardiac resuscitation medications"... still have yet to figure out if that's epi/atropine/lido/amio only.

Edited September 4, 2010 by Linuss

[ERDoc]

Lone Star, that was exactly my point (sorry if I didn't make it too clear and it's always great to play devils advocate as it keeps one thinking). I can see chemical vs electrial cardioversion being one of those gray areas, especially from a medicolegal standpoint. What is the difference? Are you technically resusitating, or are you only treating, with electrical cardioversion? Until this thread, I had not given it much thought. This whole thread is a great chance for some mental masturbation. Linuss posted the Texas info, which as straight forward as it seems, raises some questions. Linuss, I would have to disagree with you when you say, "So theoretically, you're fine pushing cardiac drugs such as Adenosine for svt as the law only states electrical cardioversion, and not chemical." It seems to me the law only refers to defibrillation and NOT electrical cardioversion. What about unstable VTach with a pulse? Can we cardiovert (again, the law only states defibrillation and we are clearly not fibrillating yet)? What about a pulseless VTach? The law refers to defibrillation being used when the heart has stopped beating. What if the heart in pulseless VTach is beating too fast to fill and as a result the person is pulseless? Their heart has not stopped beating, so technically they do not meet this criteria. Gotta love the clarity of the legal system (clear as mud).