All medical personnel and first responders are obligated to follow a do not resusitate order. What about in the case of suicide? If a paramedic shows up on a call for a deliberate overdose of pills but finds a valid DNR and living will tacked to the headboard, what happens when the patient goes into cardiac arrest? Would it matter if there was a contributing medical condition (such as a terminal cancer patient)?
I’m not an expert, but I believe a DNR order only applies if a person is under direct medical care, ie a hospital, nursing home, hospice etc… I do know that they can be intrepreted very rigidly (or could be in 1988) - my mother had to have surgery, and stroke was a risk of the surgery. She was adamant that she did not want to be saved if she had a stroke. Usually patients during this type of surgery have a stroke during or right after the surgery. Mom waited 12 hours to have hers, and since she was no longer in the recovery room the DNR order did not apply and she was on a respirator before I got to the hospital. She ended up spending several miserable months in a nursing home, totally helpless and in pain and not always aware of who people were, before another surgery killed her. And they tried to revive her then - she was not competent to issue a DNR!
EMT: “Oh, sorry, I was focussed on the patient. I didn’t see the paperwork until after we had revived him.”
The patient can then try suing them for violating the DNR, if it’s valid, while awaiting trial for attempted suicide.
In most jurisdictions in the US, an unconscious person is deemed to have given consent for emergency treatment by professionals. Good Samaritan laws protect laypersons from lawsuits if they act in good faith in response to a clear need for intervention. No law I know of requires either person to examine paperwork in an emergency.
Of course if there are two lawyers within the same jurisdiction where the event occurred, a lawsuit might result.
Tris
Just curious, why would someone with a “valid DNR” take an overdose and then call EMS?
Most states have specific laws governing the use of and interpretation of DNR requests, particularly out-of-hospital DNRs; I suspect that all states require a doctor’s signature on out-of-hospital DNR forms. A clear, standard, and legal DNR form taped above a person’s bed should prevent any paramedic from beginning CPR or ACLS regardless of the judgement of the clinical circumstances (sure the scene may look like suicide, but a DNR form, executed legally, when the person was competent to make that decision, has more mojo).
A DNR is the only way in our country for people to have some control and dignity over the way in which they die. No one should be able to trump that decision if that decision is protected by law.
shyeah, right… what are the odds of that happening? :dubious:
My interpretation was that another person called the EMS.
Snakescatlady’s story makes an eloquent point about the absolute necessity to have (a) a living will and (b) a durable power of attorney for healthcare.
Especially the latter enables a trusted person to make any and all decisions about medical treatment (or lack of same) for a person who cannot do so for him/herself. Backed up by a statement of one’s preferences for end-of-life care, this is a powerful tool.
Anecdote: Once during our father’s final illness, my sister and I arrived at the hospital to find him in pain. The nurse on duty gave the usual excuse that it was “too soon” for any more meds. I referred her to the copy of his living will and to the DPA in his chart folder, and directed that he WAS to be made comfortable. When she still was reluctant I got his doctor on my cell phone and handed it off to the nurse. If we had not the DPA there would have been little, if anything, we could do.
Be aware that in at least some jurisdictions (Wisconsin being one) it’s important to have one or the other, but not both, as the provisions and purposes of the two documents may contradict each other.
IANAL, etc.
Interesting. The forms we have here for a living will enable you to check off what you would or would not want done, plus space to add other preferences, and to name a person to make decisions for you if you can’t do so. The durable power of attorney for health care needs IIRC to be drawn up by a lawyer (I know mine is) and gives legal authority to the designated person(s) to control any medical decisions. I would guess this has to do with situations that are not covered by the living will. Certainly a person should assure that the living will and the DPOA are compatible and don’t name different people with the same authority.
Another document that was beyond price for us was a durable p.o.a. that let my sister pay our father’s bills out of his bank account, apply for Medicaid for him, etc.
This would last about 5 seconds in a courtroom. IF there is a DNR, don’t call EMS. If you call EMS and they show, expect them to initiate rescuitation attempts until the orders can be confirmed by base hospital contact. I had to do this once when family members informed us of the DNR but refused to let us see it. What did they expect us to do?
Hospital will attempt to contact the patients physican and confirm DNR status so EMS can stop working the patient. Medical information systems have grown by leaps and bounds since my days so DNR status may be more readily available to EMS and ER teams but if in doubt, run the code, sort out the paperwork later. Like a DNR, implied consent is a powerful tool. Short of tatooing DNR on the persons forehead don’t plan on EMS looking for any paperwork when they come in to a scene with a pulseless non breathing patient.
Some important clarifications about the issues in this thread:
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DNR. Do not resusitate. This is a specific and separate request, completely separate from a living will (more on this later) stating that if you die from sudden cardio-respiratory arrest, NO measures are to be taken to try to bring you back to life. A competent (legally speaking here) person, or their Healthcare Power of Attorney (HCPOA), makes the DNR decision. Once made, that decision is converted to an order in a hospital chart, confirmed/signed by the patient’s attending physician for that hospital stay (or in some circumstances, the order is entered in the Emergency dept by the ED doc, if appropriate, to allow you to die in the ED before you are admitted to hospital or discharged home). There are also provisions for DNR orders to be written for out-of-hospital (e.g. to tape above your bed so that the EMTs don’t try to bring you back from the dead at home/nursing home). Without a valid DNR order, all medical personnel are obligated to “code you” (attempt to resusitate you), no matter what the clinical circumstances might be. HAVING A LIVING WILL IS NOT THE SAME AS HAVING DNR STATUS.
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Living will. Also called Advanced Directives. A document in which you legally express your wishes for the kinds of medical/end of life decisions you wish to be made on your behalf if you are not able to do so for yourself. These take on very different dimensions depending on your local laws, on the individual preferences of the patient, etc. This is a legal document that is executed by you, when you are competent to do so, directing the health care system to do certain things, or not do them, if you are so sick or otherwise incapacitated that you can not make those choices for yourself. You may state in your living will, that if you have a terminal disease, you want to be allowed to die a natural death, but until a valid DNR order is in place, in whatever form is recognized by your state laws, you will still be subjected to CPR, etc. if you suddenly die. A living will is designed to give direction to those who will make decisions when you can’t, so be as specific as you possibly can. If you want to be “DNR”, but don’t have a DNR order, tell folks in your living will under which circumstances you want to be “DNR”. Every adult, regardless of age, should have a living will - it is the greatest gift you can give to your loved ones if you suddenly start to shuffle off this mortal coil.
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Healthcare Power of Attorney. Your legal representative for medical decisions on your behalf when you can not make the decisions yourself. Someone who will make sure your living will requests are followed, or someone who will make very tough choices about your care based on the fundamental principles you have outlined in your living will. You designate this person when you are legally competent to do so. If you don’t have a HCPOA, state laws will dictate the order in which family members have the right to make decisions on your behalf, beginning with legal spouse. Families are often in bitter dispute of what “Mom would have wanted” when there is no living will, and no HCPOA is established in advance of the crisis. Your HCPOA can specify a DNR order for you, but if you have no DNR order in effect, have no living will, and have no HCPOA to make sure the DNR order is made, you will be “resusitated” no matter what the clinical circumstances.
I hope this helps folks understand these complex and frightening circumstances. In my view, having the abililty to make a living will, choosing a HCPOA, and if you decide to do so, “being DNR” are ways of making sure that you have some control over your ultimate destiny. And again, doing this kind of “morbid” decision-making in advance can be the most wonderful gift you give to those who love you and must live on after you. And, you will unburden your doctors and other medical professionals from doing things to you that they must otherwise do, no matter how futile, because you have given them permission to honor your wishes.
The “problem” with living wills and DNRs is partly that these decisions may change with time and circumstance and power of attorney, but mostly that these decisions may be unknown to the paramedics and emergency staff. Medical systems are far less developed than patients believe; acutely contacting the GP is often impossible.
If there was a valid DNR, the paramedic might well not question suicide. Since the DNR needs to be countersigned by a licensed physician, one might question why the DNR existed in the absence of a medical condition (though admittedly there are many good reasons why this may be the case). If the patient was deemed mentally incompetent of making a decision (severe depression, dementia, etc.) the power of attorney may have signed the DNR supposedly acting in the patients best interest and according to their wishes.
Some grey area exists, but neither the paramedics or doctors would likely be found liable in the presence of a signed DNR. The paramedics would talk to their supervisor and be either told to terminate the code or bring the patient to the emergency department where a decision would be made.
EMTs are trained to err on the side of caution; if there are any doubts about a patient’s wishs they must assume the patient want’s all care possible. If they spent time looking for a DNR instead of treating the patient and there was no valid DNR they could be sued for wrongful death. BTW very few jurisdictions even have laws against commiting suicide on the books; let alone prosecute people for it. Assisting in a suicide is a whole other kettle of fish.
I can’t resist responding with what may be a hijack of the OP. If the public could understand what awaited them with CPR/ACLS in many circumstances out in the field, they would make sure their DNR orders were in effect, and EMTs would not have to assume that the pt wanted everything possible. There is huge outcome difference between the witnessed arrest followed by successful code, and unwitnessed “pt down and unresponsive” followed by EMT arrival on scene after many minutes of full arrest. Don’t get me wrong, having highly trained and motivated early responders in the field CAN make the world of difference, but how many times have those of you in the professsion (physician or EMT) seen a code that was “successful” and wish it hadn’t been. I often wonder about the ethical principle of “first do no harm” and our current medical culture of coding everybody…
All sorts of issues going on here… First off, in regards to the OP, are you saying that the patient goes into cardiac arrest after EMS arrives? If so, a DNR is not a “do not treat” order. If the patient OD’d on opiates, Narcan could prevent cardiac/respiratory arrest. Otherwise, if the patient’s already in cardiac arrest the DNR would apply. Also, I’ve heard thatsome protocols make an exception to DNR orders for apparent suicides. My local protocols, however do not.
In regards to finding the DNR paperwork, for starters someone has to call 911 in the first place. Also there’s typically (but not always) a lot of people on scene for a cardiac arrest- a 2 person ambulance crew, a 2-4 person fire crew, and one or more police officers. I try to have someone either interview the family/bystanders or search the house to determine the pts history, medications, code status, etc. I have had situations where a family member has arrived with a DNR after resuscitation started. We contacted our base physician and pronounced the patient.
In regards to a living will, durable power of attorney, etc. The absolute best thing is a state/local DNR form. Colorado has one similar to what MLS describes, you can see a sample here (PDF). If you have one of these forms , properly filled out, we can pronounce in the field. CPR Directive bracelets/necklaces are nice, as well. If presented with a living will, unless it’s shockingly unambiguous, the patient will probably be transported and the ER will interpret the living will.
As much as I hate to disagree with drachillix, I have no problem with people calling 911 for patient with a DNR order. There more we can do than just pump 'em full of epi. We can assist the family through a difficult and frightening time.
I also disagree that there is a current medical culture of coding everyone. Field pronouncements are common in the system I work under. If the family indicates that the patient would not want to be resuscitated (without a DNR) we can consult with a base physician to determine an appropriate course of treatment. Also, we can and do call codes after patients have been unresponsive to 20 minutes of ACLS therapy.
St. Urho
Paramedic
[QUOTE=Snakescatlady Mom waited 12 hours to have hers, and since she was no longer in the recovery room the DNR order did not apply and she was on a respirator before I got to the hospital. She ended up spending several miserable months in a nursing home, totally helpless and in pain and not always aware of who people were, before another surgery killed her. And they tried to revive her then - she was not competent to issue a DNR![/QUOTE]
Hi thee quickly to a lawyer and have a will drawn up as well as a durable power of attorney, a living will, and a “DNR in the event of” as well. In the event of the circumstances outline above you can have peace of mind when the above is all properly taken care of. Anyone you grant POA to should be reliable and trustworthy.