It’s one of the worst calls you could run. The patient is very old and very sick, and obviously failing fast. Vital signs are deteriorating rapidly. But the very concerned and very insistent family is gathered around and demands that you “do something,” when you know there is nothing you can or should do except let this patient pass away in dignity.
The situation has faced pre-hospital providers all over the country and it puts the EMT and paramedic in an almost impossible position. In many cases, it forces the ambulance crew to put on a terrible charade starting the IV, administering the oxygen, setting up the monitor all in a futile effort to prevent the inevitable and avoid an emotional confrontation with grieving family members. Worse yet, many local protocols require that resuscitation be provided in all cases where vital signs indicate the need.
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In hospital settings, much emotional and legal trauma can be avoided. Patient advance directives in many forms can often be followed in great detail. But in the pre-hospital environment, the relationship between the patient and caregiver is often brief and emergent. Medical considerations often prevent accommodating detailed patient wishes.
In cases of cardiac or respiratory arrest, irreversible brain death as a result of a lack of oxygen can occur in as little as six minutes. Much of that six-minute window is often used up in placing the call for service and in the response to the scene. This leaves little time for the EMS crew to interpret and carry out advance directives. This writer has been confronted with a variety of patient directives, ranging from handwritten notes expressing vague wishes that “nothing special” should be done in case of imminent death to a 10-page document that it would have taken a law school professor to understand.
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Because of the special nature of EMS, many states are now adopting a uniform, easily recognizable document the EMS/DNR (do not resuscitate) order. DNR orders allow rapid identification of people who have chosen, directly or through their legal representatives, to receive comfort-giving palliative care rather than aggressive life-saving resuscitation.
For a DNR order program to be successful, the program must be fully integrated into all aspects of your EMS system. It must have the full support of your local medical community, your medical control physicians, EMS management, field providers and the public at large.
A number of states have instituted DNR protocols. The most successful programs have been implemented on a statewide level to ensure uniformity in all health care facilities. Firehouse® has surveyed several state DNR protocols, all of which have common factors that may be useful if you are considering a program.
An EMS/DNR order is a physician standing order which must be followed by all licensed, certified or registered EMS personnel who respond on an ambulance or as part of an organized emergency medical service. The physical nature of the EMS/ DNR order will have to be worked out at your state or regional level, but in the most effective programs they are: attached to the patient’s wrist or a necklace; kept on the patient’s chart with the original available at the facility’s office; at the patient’s bedside or refrigerator door at home; or in schools or other educational institutions, where they may be kept in the nurse’s office or health room.
Resuscitation does not need to be started if the EMS crew finds a valid EMS/DNR order, bracelet or hospice card, or if the crew is given a valid order by a physician on the scene who is willing to sign the death certificate and stay on the scene until the arrival of the police or the medical examiner. DNR is also valid if ordered by a base station physician with access to a valid request from the patient. Under the programs surveyed, resuscitation can also be stopped if the EMS crew finds a valid DNR order once care has begun or by valid order of a physician on the scene or medical control.
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It’s important to understand that “do not resuscitate” does not give the EMS crew the authority to walk away from a dying patient. A crucial item in DNR protocols is “palliative care.” Essentially, this means making the patient comfortable and administering basic, non-invasive care.
Treatments authorized as palliative care include administering oxygen at 50-100 percent by mask without ventilatory assistance, suction and positioning the patient for comfortable breathing. Standard direct pressure treatment is authorized for bleeding, but no MAST trousers or IVs. Frac-tures should be treated to minimize pain and further injury.
One other factor to consider is that the EMS/DNR order can be revoked at any time by the patient by tearing up the original DNR request form in the presence of witnesses or by the patient telling the EMS crew that resuscitation is desired.
The Maryland Institute of Emergency Medical Services Systems (MIEMSS) recently implemented a statewide EMS/DNR protocol. It is the result of extensive research into effective programs throughout the United States. For more information on EMS/DNR protocols, contact George P. Smith, MBA, MIEMSS EMS/DNR Program Office, 636 West Lombard St., Baltimore, MD 21201. The telephone number is 410-706-8512; fax 410-706-8552.
Rich Adams, a Firehouse® contributing editor, is a volunteer EMT with the Bethesda-Chevy Chase Rescue Squad in Montgomery County, MD. He operates RDA Associates Inc., a public safety video production and consulting firm in Silver Spring, MD. Send story ideas and comments via E-Mail to [email protected].
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