DNR / Living Wills - how far can they go?

[OVeractiveBrain]

There has been a lot of chatter in my area about advanced directives and living wills. DNR transfers / papers / bracelets are pretty standard: If in cardio-pulmonary arrest, do not resuscitate.

The problem becomes when the conditions of cardio AND pulmonary arrest is not present. If they have stopped breathing, a DNR does not preclude the use of intubation to maintain ventilations, nor does it preclude intravenous access and administration of medications.

To address this, at least as I know it in CT where I just came from, there are further advanced directives that are not simply DNRs. They are used to indicate food stuffs, whether a feeding tube should be placed or whether intubation or IV access should be initiated. This gets a little hairy as these papers supposedly represent the patient's wishes and should carry as much strength as a DNR. However, I have heard and seen providers disregard these forms, stating that if they are going to put in an OPA and bag, they might as well intubate as well (since this will avoid aspiration or poor patient outcomes).

Other problems that arise are when families' decisions to not lay in accordance with the directives.

I am under the impression that if there is an MDs (APRN, PA, whoever has authority) signature on the form, then we should obey it. However, when it comes to certain protocols, I am hesitant. I do agree that if they want a patient resuscitated with an OPA, I should be allowed to resuscitate with a tube. I guess I can get around that by NOT intubating, but by combi-tubing instead, but Id rather have some concept of what should be done and what should not. So I sometimes find myself torn between following the directives or delivering the maximum of my care. On one hand, I want to cover my ass by doing everything Im allowed. On another hand, I want to do the best for my patients as I can. On a third hand I want to respect the wishes of the patient and their families. On a final fourth, Id rather not increase the cost of healthcare by admitting a patient to be sustained with meds and respirators that does not want to be sustained at all.

Ethical, Moral and Economically torn.

The questions I pose to this community are these.

(1) Are there these advanced directives that attempt to dictate your care in your area

(2) What is the official (company, department, med control) rulings on these in the prehospital setting?

(3) What are YOUR own feelings on these in your services.

[JPINFV]

(1) Are there these advanced directives that attempt to dictate your care in your area

Yes. Most nursing homes have their own DNR form and there is a prehospital form. It clearly states down at the bottom in the physician's order section

In the event of cardiac or respiratory arrest, no chest compressions, assisted ventilations,

intubation, defibrillation, or cardiotonic medications are to be initiated.

link: http://www.kaisersantaclara.org/images/Pre...uest%20Form.pdf

The quality of the nursing home's DNR varies from listing out specific interventions (both emergent (transfer to acute care hospital, CPR, intubation, etc) and long term (antibiotics, IV fluids, etc) care). All forms must be signed by a doctor to be valid.

(2) What is the official (company, department, med control) rulings on these in the prehospital setting?

Personally, it appears that my county is different from mosts, and I like how it is. EMS [1 med. director, 1 set of policies/protocols/scope county wide] can accept a form DNR (preference for the state prehospital form, but SNF forms are ok too), a written and signed DNR order from the chart [personal policy is to transport with a copy of it, but all we have to do is note the order, date, and physician who wrote it], or accept a "verbal request to withdraw or withhold resuscitation measures" from a family member (spouse, adult children, parents, domestic partners). DNRs can be revoked by any family member or the patient and if there is question to the legitimacy of a DNR order or disagreement in regard to the DNR from the family members then the patient is to be worked pending on-line medical control orders.

(3) What are YOUR own feelings on these in your services.

I feel that a patient has a right to control their medical care through advanced directives. If the patient wants to die naturally than that is their choice. I, as a provider, is both ethically, morally, and legally required to respect their wishes. Furthermore, I agree that family should be able to direct medical care if the patient is in an altered mental state. There is no reason to transport code 3 while diverting to the closest facility only to get there and have the family get the EMP to sign a DNR on the patient.

The only problem I have is that the division of my company that I work in operates in two different counties. The main county follows the policy I laid out above regarding family members, the other county does not.

[amraam840]

(1) Are there these advanced directives that attempt to dictate your care in your area

Ohio State Dept. of Health Do Not Resuscitate Orders

If a person has either type of DNR order, there is a standard protocol for treatment found in OAC rule 3701-62-05. For a patient with a "DNR Comfort Care" order, the DNR protocol is activated when the DNR order is issued. For a patient with a "DNR Comfort Care - Arrest" order, the protocol is activated when the patient experiences cardiac or respiratory arrest.

A patient with a DNR order may revoke it at any time. (By destroying the document or just saying "help me" "save me" etc..)

Under my (GMVEMSC) Protocols, as an (NR)EMT-Basic I may under DNR-Comfort Care provide:

• *Suctioning

*Oxygen

*Splint/Immobilization

*Control Bleeding

*Pain Control (Which as a basic mean placing pt. in position of comfort)

I May NOT

• *Chest Compressions

*Airway Adjuncts

*Resuscitative Drugs

*Defibrillation/Cardioversion/Monitering

*Respiratory Assistance (Oxygen and Suction ARE Permitted)

For DNR-Comfort Care Arrest, I may provide any medical treatment until cardiac OR respiratory arrest occurs.

(2) What is the official (company, department, med control) rulings on these in the prehospital setting?

For me, it will be the State of Ohio, Dept. of Health, and the Greater Miami Valley EMS Council.

(3) What are YOUR own feelings on these in your services.

We're right on the border of Indiana and Ohio so we have an Indiana license to provide EMS care but we do not have Medical Control in IN. I'm trying to find more information on our Indiana protocols. By Ohio and Indiana law we cannot follow a healthcare facility's in-house healthcare request for living decisions. I'm working to find out more about how that facility can follow it. I'm about a year behind on something I REALLY need to know and if anyone has any input on this topic, I know that we could all benefit from it since DNR affects most of us and I'm sure in the near future it will affect us all.

[AZCEP]

The questions I pose to this community are these.

(1) Are there these advanced directives that attempt to dictate your care in your area

No. Advanced directives do not dictate anything. They only suggest that the patient has made a determination of the degree of care that they want, in the event they are unable to communicate it for themselves. This is the whole purpose of having it written out and notarized.

Family members can revoke these "orders" at any time, and many do because they do not want to deal with the impending death of a loved one. Often I will inquire about the presence of a living will (though I can't legally follow it), or a DNR. If the patient and family tell me that one is prepared, I will make sure that everyone involved understands what it means can and cannot be done.

In the living will situation, if a patient has taken the time to get this drawn up, it would be quite arrogant of me to tell them that I can't follow it. I will then make sure they understand the situation and document the bejeezus out of what they tell me.

(2) What is the official (company, department, med control) rulings on these in the prehospital setting?

In the state of AZ, we have a "Prehospital DNR" form that must be signed/notarized/witnessed with photo ID of the patient on the form. When it started it had to be on 8.5 X 11 ORANGE paper, but this has since been removed. If the DNR is still in place, we are still somewhat obligated to notify medical control. If the patient does not have the prehospital form, but has some other type of documentation, I take this into account, and so does the receiving physician.

(3) What are YOUR own feelings on these in your services.

These are not as difficult to follow as people tend to make them. Provide comfort measures, allow the patient to make decisions if possible, contact medical control with questions. Do what is reasonable for the ultimate outcome of the patient, and consider how you want to be treated in the same situation.