"Do Not Resuscitate" Guidelines

This page includes:

1. Purpose
   Emergency Medical Services, Inc. (EMS), in cooperation with various local agencies has developed these procedures for the following purposes:
   
   
   1. Respect the patients wishes regarding the use of advanced directives.
      
      
   2. Assist emergency medical services providers with the difficult decision process for either initiating or withholding heroic lifesaving efforts.
      
      
   3. Provide instruction and guidance to health care providers for properly identifying patients who do not wish heroic lifesaving efforts.
      
   
   The purpose of these guidelines are to establish a protocol within the Lincoln EMS (Emergency Medical Service) System for the out-of-hospital identification of terminally ill patients who have chosen not to be resuscitated at the time of acute cardiac and/or respiratory failure.
   
   
   
2. Rationale
   
   Terminally ill patients are being encountered by out-of-hospital personnel in steadily increasing numbers. This is attributable to the following facts:
   
   
   1. Cancer is the second leading cause of mortality in the United States.
      
      
   2. The number of patients with AIDS (acquired immunodeficiency syndrome), HIV (human immunodeficiency virus) and other irreversible medical conditions is growing.
      
      
   3. Patients with these illnesses are, in many cases, able to be treated at home.
      
      
   Current procedures within the Lincoln EMS (Emergency Medical Services) System, require EMS providers to initiate cardiopulmonary resuscitation (CPR) and/or endotracheal intubation on all persons found to be in acute or impeding cardiac or respiratory failure. These heroic measures may be inappropriate in the cases of terminally ill patients who do not wish aggressive interventions to take place. The scene of a medical emergency may not be the proper setting to make such a determination. Most importantly, a "Do Not Resuscitate (DNR)" order requires careful deliberation and discussion between the patient, the patients family and the attending physician BEFORE an emergency situation develops.
   
   In the time of an emergency, the EMS team needs to readily and easily identify a patient who has a valid DNR order in place.
   
   The American College of Emergency Physicians (ACEP) supports the concept that unless a valid DNR (do not resuscitate) status can be verified at the scene of the medical emergency, and /or physician (on-line, or on-scene) takes responsibility for withholding resuscitative efforts, out-of-hospital personnel should perform all necessary measure unless obvious signs of death are present (such as rigor mortis, dependent lividity, injuries incompatible with life, et cetera). In general, American Heart Association (AHA) standards require that a valid DNR order must be:

   1. In writing
      
      
   2. Signed by the patient's attending physician
      
      
   3. Based on information that the patient is irreparably in a irreversibly ill, and that death is biologically imminent.

   
   

   Further, the AHA offers the following definitions:

   1. Irreversible: a case of no known therapeutic measures being effective in reversing the course of the disease.
   2. Irreparable: when the course of the illness has progressed beyond the capacity of existing knowledge and technique to stem it.
   3. Imminent Death: an ambiguous term. For the purposes of this policy: in the ordinary course of events, death is likely to occur within six (6) months.

   
   

   Finally, this policy was not intended to address the needs of all DNR (do not resuscitate) patients, nor does it deal with the issue of patients with living wills who may choose to refuse medical care. While these are important and relevant issues for EMS, they are beyond the scope of this initiative. The success of the pilot program may serve as a basis for the development of similar protocols for other DNR patient groups as well as other areas throughout Nebraska.

Section II: Procedure

1. Patient Identification
   
   For this protocol to be utilized, a competent patient or legally appointed designate for health issues (in the case of an incompetent patient) must request no resuscitation by signing the Do Not Resuscitate (DNR) consent and there must be a valid order from a physician for "no resuscitation." Once the DNR ORDER FOR THE TERMINALLY ILL form is received by the local designated agency, and identification bracelet will be provided to the patient.
   
   Step 1:
   

   Information concerning the program will be provided to the patient and the patient's family by the attending physician or the designated local agency. If the patient wishes to participate, the patient signs the DNR (do not resuscitate) consent form. The attending physician will discuss this with the patient's family and then signs the DNR order. The form can then be mailed or delivered in person to the designated local agency. (Any family controversy should be resolved before the form is signed by the patent and physician).

   Step 2:
   

   If the forms have been filled completely and signed appropriately, the designated local agency will then issue an identification bracelet with the patient's name, social security number, renewal date (6 months from the date of bracelet application) and usual destination hospital Emergency Department phone number.

   Step 3:
   

   A designated local agency representative will confirm the patient's identity and place the bracelet on the patient's right wrist (if use of the right wrist is contraindicated, the left wrist may be substituted). The local agency representative will then attest to these procedures by signing the DNR ORDER FOR THE TERMINALLY ILL form, witnessed by the family. An intact DNR (do not resuscitate) bracelet must be attached to the patient's wrist in order for the program to be valid.

   Step 4:
   

   Once valid forms are received by the local agency office, copies will be sent to the patient, attending physician and local hospital Emergency Department for informational purposes.

   Step 5:
   

   The designated local agency will properly instruct the patient's family on how to handle emergencies and to make the appropriate calls when death occurs. If the EMS (Emergency Medical Services) System is inadvertently activated, the following steps will be employed:

   
   
   
2. EMS (Emergency Medical Services) Procedures
   
   Step 1:
   

   EMS personnel will be dispatched as usual. Upon arrival, the EMS (Emergency Medical Services) personnel will assess the patient in the appropriate manner. If the patient has signs of life, then the patient will be treated and transported following established protocol. If the patient has an intact DNR (do not resuscitate) bracelet in place, Medical Direction should be consulted prior to endotracheal intubation, defibrillation, cardioversion or external chest compressions.

   Step 2:
   

   If the patient has no signs of life, then proceed as follows:
   
   

   1. CPR (cardiopulmonary resuscitation) should not be initiated if the patient has obvious signs of death as previously described.
      
      
   2. If none of the above are present, then the patient's wrists will be checked for a valid DNR identification bracelet (including current date of renewal).
      
      
   3. If the DNR identification bracelet is present and intact, NO RESUSCITATION WILL BE INITIATED.
      
      
   4. If there is not a DNR identification bracelet, or if the bracelet has been cut or removed from the patient, CPR (cardiopulmonary resuscitation) will be initiated.
      
      
   5. For informational purposes, the EMS personnel will notify the local emergency department indicated on the bracelet of the patient's demise.
      
      

   It shall be the responsibility of the local agency and attending physician to appropriately educate each patient. All aspects of the program must by in place in order for the program to be valid.
   
   If the patient, or the patient's family wishes to rescind the DNR order at any time, they would need only to cut the bracelet off the patient's wrist. In order for the program to be valid, the bracelet must be intact and attached to the patient's wrist.