NORTH COAST EMERGENCY MEDICAL SERVICES Policy # 2307
POLICIES AND PROCEDURES
Subject: Medical Control
Do Not Resuscitate (DNR)
Associated Policies: 2304, 2305
I. Authority and Reference
A. Division 2.5 of the Health and Safety Code.
B. California Code of Regulations, Title 22.
C. North Coast Emergency Medical Services Policies and Procedures.
D. Guidelines for EMS Personnel Regarding Do Not Resuscitate (DNR) Directives.
II. Purpose
To establish criteria for an Emergency Medical Technician (EMT) of any level or Public Safety Personnel to determine the appropriateness of either:
A. Withholding resuscitative measures, or
B. Obtaining a Base Hospital Physician order for pronouncement of victims of cardiac arrest while in the prehospital setting.
III. Policy (Definitions)
A. Do Not Resuscitate (DNR) means no chest compressions, no defibrillation, no assisted ventilation, no endotracheal intubation, and no cardiotonic drugs. The patient is to receive full treatmentother than resuscitative measures (i.e., for airway obstruction, pain, dyspnea, major hemorrhage, etc.).
B. Absent vital signs: Absence of respirations and absence of carotid pulse.
C. DNR Medallion: metal or permanently imprinted insignia worn by a patient, that has been manufactured and distributed in accordance with EMS requirements, is imprinted with the words "Do Not Resuscitate, EMS," and is approved as a directive for EMS personnel to withhold or discontinue resuscitation on the wearer.
D. Emergency Medical Services Prehospital Do Not Resuscitate (DNR) Form: the recommended form which is standardized and recognized statewide in California.
IV. Procedure
A. All patients with absent vital signs who are not "obviously dead" shall be treated with resuscitative measures, unless EMS personnel are presented with a written, signed order in the patient's medical record or a completed prehospital DNR request form stating "Do not resusciatate," "No code," or "No CPR," or the patient is wearing a DNR Medallion.
B. If the patient is conscious and states wishes for resuscitative measures, the DNR order must be ignored.
C. The presence of a DNR order, the physician's name signing the order and the date of the order is to be documented on the Prehospital Care Report (PCR).
D. If patient transport is undertaken, the DNR form (original or copy) or DNR medallion is to be taken with the patient.
E. Contact the base hospital as needed.
F. If CPR has been initiated and a valid DNR order is present, CPR may be discontinued without base hospital contact.
V. Conditions
A. WHEN IN DOUBT, RESUSCITATION SHOULD BE INITIATED AND THE BASE HOSPITAL CONTACTED IMMEDIATELY.
B. A valid DNR request form must be written and consist of the following:
1. The words "DO NOT RESUSCITATE" or "NO CODE" or "No CPR"
2. The patient's name and the patient's signature (or the patient's name and surrogate decision maker's name and signature)
3. The physician's name and signature
4. A statement that the patient (or responsible guardian) does not wish to have resuscitative procedures utilized and the effective date of this order.
C. A written order, signed by a physician in any health care facility (e.g., Extended Care Facility, Skilled Nursing Facility) is considered valid.
D. If the patient's physician is present, he/she may verbally order DNR; in all other situations without a written DNR request, contact must be made with the base hospital.
E. When there is a DNR order and the patient has a pulse and is breathing, the prehospital personnel should provide palliative care for the comfort of the patient, such as oropharyngeal suctioning, oxygen, pain control, etc.
F. Partial or limited DNR orders (such as "basic CPR but not intubation", or "no drugs") are valid. Any confusion regarding this should be discussed with the base hospital immediately.
H. A "Durable Power of Attorney for Health Care (DPAHC)" may be considered to be the equivalent of a DNR order if section four (4) of the DPAHC indicates that no life sustaining treatment is to be provided or continued.
VI. Special Information:
In the event the patient expires enroute, the following should be considered:
A. Unless specifically requested, the patient should not be returned to a private residence or skilled nursing facility.
B. Continue to the destination hospital or return to the originating hospital if time is not excessive.
C. If transport time would be excessive, divert to the closest hospital with a Basic Emergency Facility.
D. In remote areas, transporting agencies should make advance agreements with the office of the Medical Examiner for mutually acceptable rendezvous locations where the patient may be taken.
Approved: Date:
Approved as to Form: Date: