Do Not Intubate

[temsp40]

Never heard of do not intubate orders but I'll throw this one your way...I had a doc recently get pissed because I treated septic shock in a nursing home patient who had a DNR. Last time I checked, intubation and cpr were considered resucitation, not dopamine, iv fluids and oxygen.

hmmm....seems like another topic altogether....

BUT -- here in MA, we have the Comfort Care DNR, the only valid thing we can use for not resuscitating a patient that requests it. I have, however, run into the living will problem and as has been mentioned here before, began a BLS code, contacted medical control and explained the situation (terminal patient in cardiac arrest with no DNR present, family wishes no heroics underaken) and been told it was ok and even a good plan to stop.

CC-DNR's mean no resuscitative efforts -- BVM, intubation, Cardiac Arrest Management, not Do Not Treat -- so if the patient needs oxygen, iv therapy and cardiac medications or respiratory treatment -- have at it, take care of the patient. Also, the patient or the health care proxy (person who signed the DNR) changes their mind at any time during a DNR moment, the DNR is now void.

[brock8024]

I worked in a hospital one time that on the DNR it had areas you could check what you wanted done. Like we had codes we would not intubate others where meds only. Meaning you puish the drugs but do not do anythign else. I think either you are a DNR or Not a DNR. But on the other hand I guess it is what the family and pt want with in reason.

brock

[medic001918]

It's a decision by the patient and their family. I would have a hard time not honoring the families request. If you're ever unclear, contact medical control and explain the situation to them. Most of the time they'll go with the families decision. In hospital, they do this all the time while talking to the family.

Now as far as a DNI order, a patient can choose what they want or don't want done. There really isn't a law that says a patient has to accept all treatment or no treatment (at least in Connecticut). In the same regard that a patient can refuse a medication or any other treatment modality. I would defiantly want to talk to medical control if your protocol is not clear with regard to honoring a family request.

Now some reasonability needs to be made too so as to make sure it's a patient request and not a family dispute clouding the decision. If someone young w/o any obvious problems codes and the family says don't work them, I'd have a hard time with that. But the elderly or patient with a terminal chronic condition codes and they don't want him worked, do your best to honor the wishes of everyone involved.

Shane

NREMT-P

[Dsmittty911]

I agree with Nate on Tx rules on DNR's It's either all or nothing, but in clinical we had one who had DR and actually changed mind right before he coded on us. It didn't really affect us because we were pulling into the ED when he coded. It was worked as full code and he survived. We all had to write short documentation of what pt said just to play CYA. Living will is whole different ball game. Hey Nate or Dust, I heard something about rules for Living Will gonna change in Tx. Don't know if it was true or BS. Could you let me know if you hear anything about that. Thx

[buckeyedoc]

Ohio does not accept living wills either. You are either a DNR-CC or DNR-CCA.[/font:4ed2a12d06]

Sorry, but you are mistaken. Ohio does recognize the Living Will and HCPOA.

Ohio's Living Will and Healthcare Power of Attorney

What are Advance Directives?

"Advance directive" is a general term that refers to a person's verbal and written instructions about future medical care, in the event that the person becomes unable to speak for him or herself. Each state regulates the use of advance directives differently. There are several types of advance directives available in Ohio: the Living Will, Health Care Power of Attorney , Ohio's Do-Not-Resuscitate law, and Organ and Tissue Donation.

Why do I need an advance directive?

Advance directives give you a voice in decisions about your medical care when you are unconscious or too ill to communicate. As long as you are able to express your own decisions, your advance directives will not be used and you can accept or refuse any medical treatment. But if you become seriously ill, you may lose the ability to participate in decisions about your own treatment.

What laws govern the use of advance directives?

Both federal and state laws govern the use of advance directives. The federal law, the Patient Self-Determination Act, requires health care facilities that receive Medicaid and Medicare funds to inform patients of their rights to execute advance directives. All 50 states and the District of Columbia have laws recognizing the use of advance directives. The booklet, "Questions and Answers: Advance Directives and End-of-Life Decisions," available from Choice In Dying, offers more information about advance directives.

Ohio's Living Will is a type of advance directive in which a person puts in writing his or her wishes about life-sustaining treatments if he or she became permanently unconscious or terminally ill and unable to communicate. The person must be declared permanently unconscious or terminally ill and unable to communicate by 2 physicians before the Living Will becomes effective.

Health Care Power of Attorney is a type of advance directive that allows a person to appoint someone (an attorney-in-fact) to make medical decisions for the person in the event that he or she is unable to do so. The DPOA-HC differs from the Living Will because the attorney-in-fact appointed through a DPOA-HC is authorized to make medical decisions in any situation where the person is unable to communicate. It is not limited to the event of becoming permanently unconscious or terminally ill and unable to communicate.

Ohio's Do-Not-Resuscitate law is an advance directive which allows a person the option of not being resuscitated in the event of a cardiac or respiratory arrest. By enrolling in this program, a person has a choice to die without heroic measures, and health care providers are provided with legal means to respect those wishes. It is necessary to be enrolled in this program by a medical practitioner and have acceptable forms of DNR identification.

Organ and Tissue Donation is an advance directive choice for anyone who wishes to donate organs and/or tissues after death. By making this decision known with family ahead of time, the person's wishes may be carried out immediately and relieves loved ones of the burden of making this decision.

OHPCO provides information in a packet entitled Choices: Living Well at the end of Life. Each end-of-life option available in Ohio is discussed. Instructions and forms for completing Ohio's Living Will, Ohio's Health Care Power of Attorney, and a uniform organ donor card are also in this packet. To view and/or print the Advance Directives packet, click here.

You can find a good bit of information here. Ohio Living Will and HCPOA Information

[medstudent30]

In the hospital it is one thing, in the field it is another. We are only allowed to accept Ohio DNR-CC or DNR-CCA, no living wills. As much as I would like to, we aren't allowed to accept them. Some people feel that if they have a living will that it works the same as a DNR, but unfortunately it isn't the same when it comes to working a code at a scene or nursing home. That is one this I always ask for is a copy of the patients DNR. If it is a nursing home, they usually include a copy with their paperwork, but if it is a private residence, and they present me with a living will, I explain to the family that if something should happen, that we would have to treat the patient (for example if they quit breathing, etc). I advise them that if that patient really did not want extra measures taken to sustain their life, it is in their best interest to get a DNR-CC or DNR-CCA from their doctor. Even though I thoroughly believe in DNR's, I also believe that if they have a DNR and there is something wrong with them that they can be treated for, then they should be treated. In my opinion, DNR is their insurance policy that if something should happen, that they do not want the extra measures taken. DNR does not mean Do Not Treat, it means Do Not Resuscitate. Time and again I have had patients or their families hand me a Living Will. Yes, a patients wishes should be expressed on paper so that everyone is clear on it, but, if Ohio is going to allow hospitals to accept them, then they need to make changes for EMS. I have had so many people tell me, "This is my wish" or "This is their wish". Fine I can respect that. But Ohio Law needs to change regarding that. After explaining to the patient and/or their family about the fact that EMS is not allowed to accept Living Wills, and that they are only allowed to accept the Ohio DNR-CC or DNR-CCA, and that if their wish was really not to be resuscitated, then they need to have a conversation with their MD or DO regarding the matter of getting a DNR status. I have transported patients in the past and their family was there with them. The patient was dying. Family is there saying "Isn't there anything you can do to help them?" One of the hardest things that I have had to do was to tell them that they along with their doctor agreed for a DNR, and that the only thing I can do is to make them comfortable. Their wishes were clearly stated on the DNR. Most times now when you go into hospice care, you have to have a DNR or the hospice will not accept you as a patient. Ohio needs to just have one paper that is legal with EMS and with hospitals. That way confusion is cut down to a bare minimum, and people fully understand.[/font:36568ab689]

[buckeyedoc]

DNR's are a subject of massive confusion in Ohio. Keep in mind, the Ohio DNR laws were written by lawyers, not doctors. Yes, doctors had input, but the legal mumbo jumbo was written by lawyers. I have been threatened with lawsuits by family before because the pt. is a DNR (doesn't matter which one) and the facility could not produce a signed copy of the DNR order. Therefore, they're a full code. I had a grandson (who was an attorney) get in my face and wanted to fight when I worked his grandmother and had ROSC. He wanted to start a fight in the middle of the ER because she had a DNR, but the nursing home did not have a copy of the order (signed or unsigned). Ohio needs to re-write the current DNR law to clarify many things.

medstudent, I just want to let you know that I was not attacking you. I hope you didn't take it that way. I was just disagreeing.

Doc

[NCFD18]

the ambulance drivers not to intubate.

Wow they know the medical intervention that is called intubation, but they still call us ambulance drivers. This has to be a nurse saying this.

[NYAEMT-I]

In NY we don't honor Living Wills or Hospital DNR's. It has to be a prehospital DNR on the states DOH form. If the patient changes their mind though at any time before they code and want to be worked we then work the code..