DNR / Health care direction

Determine that patient is the correct subject of the DNR order

 

DNR means: 

No chest compressions, no defibrillation, no assisted ventilation, no basic airway adjuncts, no advanced airway, no cardiac medications or medications intended to initiate a heartbeat (Pain meds are acceptable). Patient's physician, Attorney In Fact/Health Care Agent or immediate family can verbally on scene (not over the phone) give a DNR order.

 

Exceptions:

- OK to relieve an airway obstruction

- OK to do CPAP

 

Approved DNR documents (complete & signed):

- State EMSA/CMA prehospital DNR request

- Medic Alert medallion/bracelet with engraved directions

- DNR order written by MD

- POLST (Physician Orders on Life Sustaining Treatment)

 

Immediate Family means: 

Spouse, adult child, parent of a patient, adult sibling or domestic partner: EMS can withhold or withdraw resuscitative measures if immediate family is on scene and they make a unanimous decision to withhold resuscitation.

 

Attorney in Fact or Healthcare Agent has legal authority to make medical care decisions.  MD or family must be present to give verbal orders (no phone).  Anyone giving DNR orders should sign ePCR.  

 

A DNR will be disregarded if the patient’s immediate family requests resuscitative measures BHC.

 

Declared Dead:

Resuscitative measures are not indicated for declared dead patients.  Criteria is cardiopulmonary arrest victim with one or more of the following (which must be clearly documented on PCR):​​​

  • Decomposition

  • Incineration

  • Massive crush injury &/or evisceration of heart or brain

  • Decapitation

  • Obvious fatal external exsanguination

  • Rigor mortis (see ** NOTE below)

  • Lividity (see ** NOTE below)

  • Traumatic FA (see ** NOTE below)

  • Unwitnessed, non-trauma FA with no bystander CPR or AED placement prior to EMS arrival AND found by cardiac monitor to be Asystolic in 2 leads and meets criteria (see ** NOTE below)

 

**NOTE**: 

The following must be performed and documented to meet criteria for “declared dead’:

- Open airway - looking, listening and feeling for respirations,

- Including 30 seconds of auscultation of lungs,

- Palpating a central pulse for minimum of 15 seconds,

- Auscultation of apical pulse for 15 seconds,

- Assessing for pupil response with penlight/flashlight,

- No response to painful stimuli

For any uncertainty, check rhythm in 2 leads to confirm

 

WITHHOLDING CPR

- Document name and relationship of person/s claiming to be immediate family on PCR 

- If honoring requests by family

- Patients own written request is honored over family member/s requests.  Make Base contact to advise of situation

- When using an ePCR put Coroner as the “Actual Destination” at the bottom of the form

**If ALS treatment is started, BHC needs to be made in order to stop treatment**

 

Caution:

- Normal skins may appear as lividity, poor hygiene/gangrene may be mistaken for decomposition. 

- Burn victims appearing incinerated may be alive.  Confirm rhythm in these patients with cardiac monitor. 

- Hypothermia (especially in children, elderly and debilitated) may simulate death.

Call

M: 949-769-1162

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