DNR... Are YOU sure? Justin Lammers ACP Paul Bradford Local Medical Director.

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1 DNR... Are YOU sure? Justin Lammers ACP Paul Bradford Local Medical Director

2 Learning Objectives Explain what a DNR is, it s rational, and how it relates to paramedic practice. Discuss the meaning and implications of the DNR Confirmation Form. Describe treatments and procedures that can and cannot be performed on a patient who has a valid DNR. Describe how a valid DNR might alter paramedic practice in a variety of patient care scenarios. 2

3 Outline What is a DNR? DNR Validity Substitute Decision Makers Revoking a DNR What if DNR Scenarios 3

4 What is a DNR? DNR is an abbreviation for Do Not Resuscitate. This is a legal order written on a legal form, respecting the patients wishes to not have CPR or ACLS interventions in the event they suffer cardiac or respiratory arrest. * * Although this is the definition, the confirmation form brings about great debate regarding treatment up to and including cardiac arrest. 4

5 What is a DNR? As stated on SWORBHP s website Ask Mac -think of the DNR confirmation form as a list of specific patient instructions of how they wish to be treated when they become extremely unwell or have arrested and they are unable to communicate for themselves. - March 1,

6 What is a DNR? DNR means that the Paramedic (according to scope of practice) will not initiate basic or advanced CPR such as: Chest compressions Insertion of OPA/NPA Defibrillation ETT Drugs such as but not limited to: Vasopressors Opioid antagonists Antiarrhythmic agents Artificial Ventilation TCP 6

7 What is a DNR? If your patient has a DNR confirmation form, none of the treatments listed prior should be initiated. The DNR confirmation form does not state that arrest must occur to void these procedures. Consider pre arrest and arrest states. 7

8 What is a DNR? An example stated on Ask MAC: If a patient has a signed a valid DNR confirmation form, and has a decreased LOC with oxygen saturations of 60% despite 100% FIO2, but has a perfusing rhythm and blood pressure, this patient should not be intubated. - March 01,

9 What is a DNR? For the purposes of providing comfort/palliative care, the Paramedic (according to scope of practice) will provide interventions or therapies considered necessary to provide comfort or alleviate pain. These include but are not limited to the provision of: Oropharyngeal suctioning O2 NTG Salbutamol Glucagon ASA Epi for anaphylaxis Benzodiazepines Morphine or other opioid analgesics 9

10 What is a DNR? The previous list of items in part 2 of the confirmation form are to be used to comfort or ease pain in the patient, as your standard protocols would normally be used. This shows that despite the patient having a valid DNR, treatments are still available for this patient. 10

11 DNR Confirmation Form February 1, 2008 was the beginning of the new DNR Confirmation form. This is a standardized form for all Paramedics and Firefighters for follow. This form when signed by a MD, RN, RNEC, RPN confirms the existing care plan does not include CPR. 11

12 DNR Confirmation Form This form is different from Hospital DNR s as it is stating either CPR or not. Within hospitals there are different levels of care that may be chosen. It was decided that to alleviate confusion on scene, there would be one standardized option. If the patient is transported to hospital, the physician could then sit down with the family and discuss different treatment plans. 12

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14 What is a DNR? Where a patient is being maintained by equipment leave it in place Ie: Intubation If the patient does suffer cardiac or respiratory arrest, no additional interventions are given. ***Do you shut the vent off if they code?*** 14

15 DNR Validity On this form is a unique 7 digit serial number. Confirms authenticity of the form If no serial number is found - form is invalid Durable Document Meaning that this one form is used several times. Photocopies are acceptable as the master copy may remain in a safe location. 15

16 DNR Validity Required Information 7 digit serial number All fields filled out A valid health care provider must sign the form. If at anytime it is determined that the form is not valid - continue care and treatment. 16

17 DNR Validity Checked First Box: indicates a plan exists that doesn t include CPR. indicates that this was the patient s or SDM s wishes. Checked Second Box: indicates the physicians opinion: CPR will almost certainly not benefit the patient will have been discussed with the patient or SDM. 17

18 Substitute Decision Maker SDM Substitute decision maker Assigned by the patient to make health related decisions if the patient cannot make them or is deemed incapable. This person is usually chosen by the patient prior to illness or injury. 18

19 Substitute Decision Maker If nobody is selected by the patient prior to illness: Guidance in the health care consent act identifies the legally authorized SDM. 19

20 Substitute Decision Maker Power of Attorney: Determined when the patient is well POA for Personal Care Form must be complete MOH states: Paramedics are not expected to investigate the condition under which a DNR order is made nor are they required to review or confirm the DNR order written in the patient health care record. Paramedics must make a reasonable attempt to confirm the patient is who is named on the form. Verbal confirmation from family or staff is acceptable. - MOH DNR Standard Training Bulletin

21 Revoking a DNR A DNR can be Revoked: At anytime by the patient or SDM If the physician or RN has determined the treatment plan has changed and now includes CPR If a patient or SDM withdraws consent and expresses wish to have CPR If a DNR cannot be produced or is taking a while to be produced 21

22 What if...? Should you honour a patient s DNR if they are choking? "The duty of all paramedics and front line providers is to assist patients. A valid DNR does not preclude a paramedic from attempting to assist a patient who is choking. However, once a patient has suffered a cardiac arrest -for whatever the reason- and this patient has a valid DNR, then the DNR is to be followed as described". - Jan 19,

23 What If? Is a valid DNR a good reason to not transport critically ill patients at a high CTAS level? A DNR should in no way influence the CTAS scoring. It is not listed as a modifier in the latest teaching package from MOHLTC. - March 01,

24 What if.? The DNR confirmation form states the paramedic will not initiate basic or advanced CPR such as, TCP?. From what I understand, until that person suffers cardiac or respiratory arrest, they are fair game for treatment. So, if a patient is in a 3rd degree block at 20bpm and they have a DNR, we are pacing this patient? 24

25 What if.? if a valid DNR Confirmation Form is available, none of these "advanced cardiopulmonary resuscitation" procedures should be initiated period. The SWORBHP Medical Directors would suggest that this is independent of whether the patient has completely arrested or not. 25

26 What if.? If there is an on scene delay in obtaining the DNR validity form, what do we do? If there is a delay in obtaining the fully completed DNR Confirmation Form in a patient who has suffered a cardiac arrest, CPR is to be initiated until such time as the form is produced. Alternatively, paramedics should follow local policies where they exist for termination of resuscitation. Patching to the BHP is always an option. - Feb 06,

27 Questions? 27

28 Resources cisions.pdf %20Resources/Forms/DNRCF.asp html tin_108_v1_dnr_standard.pdf 28

Municipal EMS Directors and Managers CAOs of Upper Tier Municipalities and Designated Delivery Agents Ornge

Municipal EMS Directors and Managers CAOs of Upper Tier Municipalities and Designated Delivery Agents Ornge Ministry of Health and Long-Term Care Emergency Health Services Branch 5700 Yonge Street, 6 th Floor Toronto ON M2M 4K5 Tel.: 416-327-7909 Fax: 416-327-7879 Toll Free: 800-461-6431 Ministère de la Santé