It has been almost 13 years since the Colorado CPR directives have been reviewed. In that time frame, there have been many versions and interpretations of the directives. Some of those interpretations have made things harder for field providers and confusing for the very people that it was intended to help. In 2010 the revisions and amendments were formally incorporated into the new document, 6 CCR 1015-2, Rules Pertaining to the Implementation of Cardiopulmonary Resuscitation (CPR) Directives by Emergency Medical Service Personnel. This bill has been approved by both houses in the legislature and is scheduled to be implemented by all parties in August of this year. The complete document can be found on www.coems.info. This class will update you on the revisions and a new form, called: Colorado Medical Orders for Scope of Treatment, otherwise known as the MOST form, that you may encounter. The Colorado Revised Statutes (C.R.S.) have been scanned and are on your website and have been copied and included in your packet for your reference. 1
This is what you will learn in this session. In a nut-shell: 1. There is no requirement for a person to have a CPR directive; 2. If a CPR directive is desired, the subject of the directive must be described; 3. The directive must be in writing; 4. There are a variety of types of directives, most of which will be described; 5. There are definitions to learn; and 6. EMS is considered an important part of the implementation and success of this program. 2
The statute incorporates several definitions. The definition of CPR is: Rules Section 2.6 Cardiopulmonary Resuscitation (CPR) means measures to restore cardiac function or to support breathing in the event of cardiac or respiratory arrest or malfunction. CPR includes, but is not limited to, artificial ventilation, chest compression, delivering electric shock, placing tubes in the airway to assist breathing, or other basic and advanced resuscitative therapies. You will note that this is a more expansive definition of CPR under the statutes and regulations. 1. More inclusive than the combination of chest compressions and artificial respiration. 2. Encompasses the use of airway adjuncts, with or without manual ventilations. 3. The regulatory definition also encompasses more than asystole and ventricular fibrillation - but any form of respiratory or cardiac arrest or malfunction. a. For example, a CPR directive would include ACLS procedures not commonly considered CPR, i.e. pacing. 3
The statutes also include other definitions, such as: 2.3 Authorized Agent : means any person who, pursuant to the laws of this state or any other state, is authorized to make medical treatment decisions concerning the withholding of CPR for an adult who lacks decisional capacity or for a minor, pursuant to Section 15-18.6-102, C.R.S. Authorized Agent includes but is not limited to a court-appointed guardian, an agent with healthcare decision-making authority appointed in a power of attorney, and/or a proxy selected pursuant to Section 15-18.5-103, C.R.S. 2.7 CPR Directive : means an advance directive pertaining to the administration of cardiopulmonary resuscitation. 2.8 Declarant means a person who has executed a CPR Directive. The declarant may be the individual named within the directive or the authorized agent of that named individual. 2.10 Do Not Resuscitate Order (DNR) : means a physician order to refrain from cardiopulmonary resuscitation. 2.12 Individual : means the person who is the subject of a CPR Directive. 2.13 Palliative : refers to measures and treatments intended for relief of pain and suffering including, but not limited to, medication by any route, positioning, oxygen, suction, and manual treatment of airway obstruction as needed for comfort. 4
This is the internet site where the full document is located. This document explains the WHO, WHAT, WHEN, WHERE, WHY, and HOW of CPR Directives and other related issues. This Legal Resources website not only contains the entire Colorado Revised Statutes, *Fortythree different TITLES + but it also has information about the Colorado Court Rules, and the Colorado Advanced Legislative Service (463 different chapters ). You can also find copies of the Colorado Constitution and the US Constitution as well as, a General A to Z Index. Today s focus is on TITLE 15 Declarations Future Medical Treatment section. This section contains Articles 18, 18.5, and 18.6, all of which, have important information for this course. Title 15- Article 18.6-101 thru 108, C.R.S. Directive Relating to Cardiopulmonary Resuscitation: (Can be viewed at http://www.michie.com/colorado) : 102 Who May Execute a CPR directive 103 CPR Directive Forms Duties of state board of health 104 Duty to comply with CPR directive immunity effect on criminal charges against another person 107 Revocation of a CPR directive 5
The revised rules are more concise and have been simplified. Any contradictions have been eliinated and areas of confusion have been clarified. The end result is that individuals have greater access to making CPR directives, and health care professionals, both pre-hospital, inhospital and hospice, have more guidance and protection in attempting to implement the directives. 6
In Section 1 the focus is on the Purpose of a CPR Directive and the Authority of both EMS personnel as well as the patient. Those points include: An individual is not required to have a CPR Directive, and they don t have to use any SPECIFIC form. It specifically states that Nothing in these rules shall be construed to alter or interfere with the appropriate exercise of clinical judgment, or to alter the standards of medical practice or the principles of medical ethics. It provides protection for EMS personnel by stating: A. It is the intention of these regulations to protect the welfare of patients and to respect the appropriate exercise of professional judgments made in good faith by emergency medical service personnel. B. A CPR Directive shall not preclude evaluation by emergency medical service personnel for appropriate and available medical and palliative services. 7
Within Section 2 there are some key definitions worth knowing. They include CPR Directive, Do Not Resuscitate, Advance Directive, Individual, and Palliative. The definition of Authorized Agent from Section 2 was expanded upon. The term Authorized Agent includes but is not limited to a court-appointed guardian, an agent with healthcare decision-making authority appointed in a power of attorney, and/or a proxy selected pursuant to Section 15-18.5-103, C.R.S. 8
Section 3 contains the General Provisions for CPR Directives and simply states that a CPR Directive shall contain the following information a.name, date of birth, sex, eye and hair color, and race or ethnic background; b.if applicable, the name of the hospice program in which the individual is enrolled; c.the directive concerning the administration of CPR to the individual; d.the signature or mark of the individual or authorized agent; e.the date on which the CPR Directive was signed by the individual or authorized agent; f.the name, address, telephone number, and signature of the attending physician; and g.a written statement and signature(s) indicating a decision regarding tissue donation upon a patient's death, consistent with the revised uniform anatomical gift act, Section 12-34-101, C.R.S., et seq., then in effect. This section does a number of other things including: Highlights that an authorized agent can sign (& date) the directive if the declarant is unable to sign or mark it. Simplifies the rules for a CPR Directive bracelet or necklace. (3.1.2 states: A CPR Directive may be made in any other manner. ) Explains when EMS personnel have lawful authority to withhold CPR. (See: 3.1.3) Confirms that the declarant can revoke a CPR Directive at any time, and an authorized agent can only revoke a directive if he/she was the ORIGINAL signer. (See: 3.2.1) 9
EMS personnel may see many different types of directives in the field. There is a form that is located on the State's website (www.coems.info). The original form, referred to as the "blue" form, is still accepted in the state. Other forms that you may encounter include: M.O.S.T. form : Medical Orders for Scope of Treatment form. A physician s order that outlines a plan of care respecting the patient s wishes concerning care at life s end. P.O.L.S.T. form : Physician Orders for Life-Sustaining Treatment form. A physician s order that outlines a plan of care respecting the patient s wishes concerning life-sustaining treatment at life s end. Living Will: In Colorado known as "Declaration as to Medical or Surgical Treatment". This document allows the individual to express, in advance, how he/she wishes to be medically treated in the event of a terminal condition. (See: Title 15-18-104 C.R.S.) Do NOT Resuscitate Order (DNR): A physician s order to refrain from cardiopulmonary resuscitation (CPR). Five Wishes form : A type of Living Will. One of the most popular living wills because it is written in everyday language and helps start and structure important conversations about care in times of serious illness. Other forms and documents that you may need to know about includes the Medical Power of Attorney. This is a document where you may designate whom you wish to speak for you in the event that you are unable to speak for yourself concerning medical treatment. This person is known as your Authorized Agent or more simply, Agent. Unlike a Living Will, a Medical Power of Attorney is NOT limited to terminal conditions. (Routine medical procedures and treatment are also included). The Medical Power of Attorney has been known by a variety of terms, including: Durable Power of Attorney ; Health Care Power of Attorney ; Power of Attorney with Durable Provisions ; and Enduring Power of Attorney, etc. There are many more, these are just a few of the better known terms. 10
These are just two examples of the different forms that can be used for end-of-life wishes. There is nothing in the rules that limit the manner in which a person may make a CPR directive or to require the exclusive use of any specific CPR Directive form. On the left is the Blue form that has been used in the past, and is still accepted. On the right is the template that can be found at www.coems.info (CPR Directives). Because people have asked for an example of a form, this one was created and posted on the state website. This form may become more commonly encountered. Keep in mind that some forms may have a variety of signatures, however a declarant (individual or authorized agent) and a physician are always required to be considered a valid CPR directive. The template on the state's website (www.coems.info) may be used to create a CPR directive. Commercially produced forms are also available through internet documents, hospitals, legal sources, health care agencies, etc. 11
Because no one is limited to the form of the directive, jewelry such as bracelets, necklaces, watch charms, etc. are available. However, jewelry may only have a small portion of the required patient information. 12
Section 4 highlights the General Protocol for Implementation of CPR Directives. Focuses mostly on EMS personnel general protocols and procedures when faced with a CPR Directive in-the-field. Defines what types of forms a patient may possess, and what personal information and signatures make a directive valid. Reviews who can revoke a directive. Re-visits the definition of CPR. Discusses the procedures EMS personnel must follow, and re-visits the concept of following local medical direction and pre-hospital protocols. 4.2.1(a): This may include, but is not limited to, documents such as a living will, medical durable power of attorney, CPR Directive, or other advance directives, including those from other states. (REMEMBER: 4.2.4(b) A valid CPR Directive that has been photocopied, scanned, faxed or otherwise reproduced shall be honored. ) 4.2.1(b): Any document or item of information or instruction that clearly communicates the individual s wishes or intent regarding CPR may be regarded as valid and the individual s wishes honored. 4.3.3: When presented with any valid CPR Directive, EMS personnel shall not attempt to resuscitate that individual. If CPR has been initiated, it shall be discontinued. Local medical direction and pre-hospital protocols shall be followed. REMEMBER: 4.2.2 An individual with a CPR Directive shall receive evaluation by EMS personnel and be provided appropriate and available palliative treatment and measures. 13
Section 5 states that there is a duty to comply with a person's CPR directive, that is immediately available; grants immunity to EMS personnel, who, in good faith, comply with a CPR Directive; and states that in the absence of a CPR directive, consent to CPR is presumed. The actual wording is below: Title 15, Article 18.6-104: Duty to comply with CPR Directive: (1) Emergency medical service personnel, health care providers, and health care facilities shall comply with a person's CPR directive that is apparent and immediately available. Any emergency medical service personnel, health care provider, health care facility, or any other person who, in good faith, complies with a CPR directive shall not be subject to civil or criminal liability or regulatory sanction for such compliance. (2) Compliance by emergency medical service personnel, health care providers, or health care facilities with a CPR directive shall not affect the criminal prosecution of any person otherwise charged with the commission of a criminal act. (3) In the absence of a CPR directive, a person's consent to CPR shall be presumed. (pursuant to Section 15-18.6-104 C.R.S.) 14
When you discuss these, make sure you bring your conclusions to class. We will be talking about any controversies that might come up or any confusing points as related to your experience and our protocols. 15
The following three(3) scenarios could possibly occur at a patient s home. Discussion of these scenarios should always bear in mind not only the CPR Directive Rules, but also medical direction, MV protocols, and procedures. 16
EMS is called to a 88 y/o male in cardiac arrest. Upon arrival, EMS personnel find PT lying supine in hospital-type bed. PT not conscious, not breathing. Family immediately provides what appears to be a valid CPR directive. Discussion Questions: 1) What are EMS personnel procedures when presented a CPR directive? 2) What type of information should EMS personnel look for on the directive to deem it valid? 3) What other signature MUST be on the directive in this case? 4) What types of care could you give to the patient and the family? 17
EMS is called to 88 y/o male in cardiac arrest. Upon arrival, EMS personnel find PT lying supine in hospital-type bed. PT not conscious, not breathing. Family immediately provides what appears to be a valid PHOTOCOPY of a CPR directive. Discussion Questions: 1) Besides a photocopied directive, what other types of documents are accepted? 2) What if the photocopied document is illegible? 3) What are EMS personnel procedures when presented any type of CPR directive? 4) What type of information should EMS personnel look for on the directive to deem it valid? 18
EMS is called to 88 y/o male in cardiac arrest. Upon arrival, EMS personnel find PT lying supine in hospital-type bed. PT not conscious, not breathing. Family immediately points out the PT is wearing what appears to be a valid CPR Directive BRACELET. Discussion Questions: 1. What are EMS personnel procedures when presented a CPR Directive bracelet? 2. What type of information should EMS personnel look for on the directive to deem it valid? 3. What type of information will fit on a small bracelet? Does this make it valid? 19
The following THREE scenarios are very common in the field: Emergencies that occur with home hospice, at a hospice care facility, nursing homes, assisted living facilities, and/or long-term care facilities etc. are also very common. Since we don't have any assisted living facilities or long-term care facilities in our district, we will in the future. We do, however, have people with terminal conditions, being cared for at home. Take a look at these cases... 20
EMS is called to 77 y/o female with heart problems: your pt pushed medical alarm button & 9-1-1 was called. Upon arrival EMS personnel are led to the bedside of pt by a hospice care giver; pt is awake, complains of chest pain, and states she feels weak; the pt verbally states she wants CPR performed if things go bad. The pt becomes unconscious. Discussion Questions: 1. How is a CPR Directive revoked? And by whom? Are there any exceptions? 2. What if the unconscious patient is NOT in cardiac arrest? 21
EMS is called to 77 y/o complaining of heart problems: pt pushed Medical Alarm button & 9-1-1 was called. Upon arrival EMS personnel are led to the bedside of PT by family member; PT complains of chest pain, and feels weak; PT becomes unconscious. Family provides a CPR Directive from another STATE. Discussion Questions: 1. Are CPR Directives accepted/valid from another state? 22
EMS is called to 77 y/o complaining of heart problems: pt pushed medical alarm button & hospice along with 9-1-1 is called. Upon arrival EMS personnel are led to the bedside of pt by hospice employees; pt complains of chest pain, and feels weak then becomes unconscious. Hospice employee can t locate the CPR directive in the paperwork. Discussion Questions: 1) What should EMS personnel do when a CPR Directive is not apparent and immediately available? 23
The following THREE scenarios are emergencies that occur in public places. 24
EMS called to downtown Erie; a 58 y/o male feels ill, dizzy, weak. Upon arrival, EMS personnel find pt lying supine on sidewalk not conscious, not breathing, and notice a CPR Directive in pt wallet; Directive has NO declarant & NO physician signature. Discussion Questions: 1.What are TWO key signatures necessary on a CPR Directive? 2.What other signatures may be on a Directive? 3.What other KEY information should be on the Directive? 25
EMS called to downtown Erie: A 58 y/o male feels ill. Upon arrival EMS personnel find PT lying supine on sidewalk not conscious, not breathing; Son and daughter of PT introduce themselves; Daughter wants CPR; Son provides what appears to be a valid CPR Directive. Discussion Questions: 1.Who can revoke a CPR Directive? 2.How do you deal with the family members who are in disagreement? 3.If after validation of the directive, the patient is not in cardiac arrest, what treatment and care should you provide? 4.What should be done to provide care for the expired individual? 26
EMS called to downtown Erie: A 58 y/o male feels ill. Upon arrival, EMS personnel find pt lying supine on sidewalk not conscious, not breathing; Daughter has proof that she is the authorized agent; Daughter wants to REVOKE directive. Discussion Questions: 1.Can the daughter REVOKE the directive? 2.What signatures are required on the CPR directive in this scenario? 3.If the 58 y/o male was conscious and able to speak in this scenario, could the PT say: Please DON T revoke it I don t want CPR? 27
The following Scenario involves a CPR Directive for a MINOR. Dealing with children may be difficult. The following scenarios will address situations where children are involved. 28
EMS called to 9 y/o female who is unconscious. Upon arrival, parents meet EMS personnel at door and lead them into the PT bedroom, which has a hospital-type bed and other medical-type machines/items/meds in plain sight. Upon arrival, pt is lying in bed, in obvious respiratory distress. After initial assessment, pt goes into respiratory and cardiac arrest. Parents are authorized agents. You learn that the pt has terminal cancer. Discussion Questions: 1)How do we handle CPR Directives as they pertain to minors? 2)How do we handle Authorized Agents (parents/guardians) in cases like this? 3)If the parents were in disagreement, how would you deal with the situation? 4)If the parents were divorced, had joint custody and were in disagreement, how would you deal with the situation? 29
Perhaps no area within the EMS is more complex than end-of-life issues. Recognition of the impacts upon the patient of knowledge of their impeding death; the level of acceptance by family members; and, the impact of the situation upon the EMS provider is critical. Five emotional stages are generally recognized. First explored by Elisabeth Kubler-Ross in her 1970 book, On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and Their Own Families, both her book and her research remains subject to criticism. But, as a framework of understanding, the stages seem a viable starting point for discussion and understanding. The stages are: denial, anger, bargaining, depression and, finally, acceptance. You may note from your own experience that these stages are common with grieving. DENIAL: A defense mechanism. Presents with feelings of disbelief. ANGER: Begins with a little bit of frustration can increase to anger! Patients and caregivers believe it is unfair that death is near. Patients may vent anger upon their family as well as EMS personnel. BARGAINING: Agreement that, in the patient s mind, will postpone the death for a short time. Some try to cut-a-deal with a higher power. DEPRESSION: The patient retreats into a world of his/her own, unwilling to communicate with others. Looking back can lead to great sadness, regret, or despair. ACCEPTANCE: The family will usually require more support during this stage than the patient. Does NOT mean the patient will be happy about dying. Understanding these stages may be helpful to you. The time it takes to move through these stages varies with each person. 30
These scenarios should have highlighted that this is one area where law, emotion and ethics converge. Times will arise when these interests appear to be impossible to reconcile. It is then that we as EMS personnel need to contact our medical control, if possible, for guidance. 31
The Colorado CPR Directive legislation has been revised to include more than one type of CPR directive, stipulate what must be contained within a directive, provides guidance for when the directive must be followed and by whom, states who can revoke a directive and provides protection for those who honor the directive. It also provides for the rights of the patient, EMS personnel and the authorized agent as summarized below: Patient rights The right to have or NOT have a CPR Directive ( accept or refuse medical treatment ); The right to choose the type of CPR Directive (documents or jewelry and/or originals or otherwise reproduced ); The right to have an authorized agent speak on your behalf if the individual does not have decision-making capacity ; The right to REVOKE a CPR Directive; EMS personnel rights The right to follow local protocols/procedures when presented with a CPR Directive; The right to call Medical Direction for clarification/questions; Authorized Agent rights 1.The right to speak for an individual who does not have the decision-making capacity to speak for themselves 32
If you have questions, please bring them to class. 33
For Technical assistance regarding this presentation, please call Knighthorse Solutions, Inc. 719-375-3627. For more information on CPR directives, visit www.coems.info. (CDPHE website) 34