I have a question about the exact verbage of a true DNR. New Jersey Department of Health and Senior Services offers an official document that is to be used as a DNR. ALL health care facilities have access to this document for FREE. I have noticed that some facilities use different documents that say they are DNR documents but if the state says to use thiers, which is correct? I have even seen doctors write DNR on a prescrition pad and hand it to EMS. Is this a true DNR? Now the second part.....resusitate means to restart. Understood. How about when a patient only needs assistance? Lets say respiratory rate is only 5/ min. ? Do you bag this patient? Do you "let" them die? Living wills?
Situation. Nursing facility with hospice patient. Patient is near death and was recently d/c from hospital. Patient was intubated while at hospital and now has lacerations from the tube. Injury sites have some clotting and pt is already in distress. Staff removes clots to allow respirations to be effortless. Pt respirations have been about 6/minute. What to do? Is removing clots defeating DNR. Would bagging this Pt defeat DNR? My impression is that as long as the pulse and respirations are present assistance is ok. Once they stop the DNR is in affect. Any input would be greatly appreciated.

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I can't speak for american law but hopefully some of the UK practice will be able to answer some of your questions.

DNR's in the UK are referred to as Advanced Decisions to Refuse Treatments (ADRT) and can cover not just resus but whether a person wishes to be admitted to hospital, wishes to refuse IV antibiotics really any sort of treatment. The document and its decisions only apply when the patient looses the capacity to consent. The process and whether a document is valid and applicable is governed by the Mental Capacity Act (2005). As a para, I would be expected to apply the 2 stage test under the MCA and then refer to the plan if the patient lacks capacity.

There is no set form for written advance decisions, because contents will vary depending on a person’s wishes and situation. But it is helpful to include the following information:
1) full details of the person making the advance decision, including date of birth, home address and any distinguishing features (in case healthcare professionals need to identify an unconscious person, for example)
2) the name and address of the person’s GP and whether they have a copy of the document
3)a statement that the document should be used if the person ever lacks capacity to make treatment decisions
4)a clear statement of the decision, the treatment to be refused and the circumstances in which the decision will apply
5)the date the document was written (or reviewed)
6)the person’s signature (or the signature of someone the person has asked to sign on their behalf and in their presence)
7)the signature of the person witnessing the signature, if there is one (or a statement directing somebody to sign on the person’s behalf).

So long as these items are included it doesn't really matter what it is written on...I've come across one that was written on the back of the patient's electric bill. The first piece of paper that the visiting doc laid his hands on i guess.

This is a common issue particularly for us in care homes, because the care plan or documentation is never kept anywhere near the patient and in the heat of battle we're thrust medication records, DNR's, NOK details whilst trying to cannulate or intubate.

In this case, its i suppose a fine balance between AMLS and actual resuscitation and it would depend on the wording of the ADRT. "in the event that I suffer a cardiac arrest, I do not wish to be resuscitated" then your fine. If "In the event that I experience breathing difficulties, I do not wish to receive oxygen therapy" then there might be a problem.

In the UK as paramedics we must follow the DNR if we believe it is valid and applicable. If we have a genuine doubt then we can provide treatment without liability. Certainly in our area, care homes have been advised to attach certified photographs with the DNR and encourage to register the decisions with us. This is then flagged on the CAD system when a emergency call is received to the address the call taker will be asked to confirm whether it is said pt that needs ambulance and the crew is informed of the DNR via the mobile data terminal.

We will be protected from liability for failing to provide treatment if we ‘reasonably believe’ that a valid and applicable advance decision to refuse that treatment exists. But we must be able to demonstrate that their belief was reasonable and point to reasonable grounds showing why they believe this. As Paramedics, we can only base this decision on the evidence that is available at the time. In some cases, concern about the existence, validity or applicability of an advance decision to refuse treatment may be difficult. Such as, a disagreement between relatives and healthcare professionals about whether the decision is accurate (particularly if they did not know about it)

In the scenario, if the patient has capacity to consent then the DNR would not apply and the pt would decide whether they wanted help or not. If the patient lacked capacity but the decision was not covered by the DNR as i feel this case is. We would apply the best interests principle. Which allows the paramedic to make a decision and provide treatment in the patients best interests when they lack capacity. This involves considering the patients past, present and future wishes and also that of their relatives if available at the time. We would be protected from liability provided that we reasonably believe that the treatment or decision is in the patient's long term best interests. This provision applies in all patients that lack capacity not just terminally ill or advanced decisions, and can be used for the intoxicated head injury or as I have in the past the elderly patient with a fractured NOF.

Is removing the clots against DNR, really depends on wording and what is being refused. If in doubt I would, start treatment and seek clarification from the patients Dr or Emerg Doc's.

More info can be found in the following http://www.dca.gov.uk/legal-policy/mental-capacity/mca-cp.pdf, chapter 9 should cover it. This is the code of practice for all healthcare professionals in relation to applying the MCA in practice and although not US law one would assume it has some relevance.

Hope that helps?
Questions and situations like the one listed here are ones that need to be discussed with and clarified by your Medical Director and agency's administration.

I can only speak to my agency and the requirements in the Florida. The Bureau of EMS has a mandated DNR form for acceptance by EMS providers. It also has a DNR bracelet. The BEMS requires that these forms be of a particular color....yellow. Our local hospice agencies include this BEMS DNR form as part of their admission packet.

I would encourage that this type of situation be pushed up the chain for clarification and guidance.
Comfort care is appropriate, such as removing clots to ease respiration or managing pain or anxiety, etc. However, I have always understood assisting respiration when they are decreasing to be resuscitation. Similarly, if the patient's HR were decreasing (i.e. becoming bradycardic), administering atropine to increase the HR would count as resuscitation. The patient has a DNR so that they can die unimpeded. Respirations don't always just suddenly stop and same for the heart. One or both may slow before cessation (and death) occurs. You bag the patient and you are just prolonging death. Death is what is desired, and it should be respected and allowed to occur. In my most brutal opinion, I'd consider any hinderence of death a kin to torture.

Ultimately, your question is one for your medical director. If you are part of a volunteer organization that doesn't have one (seeing as you are from NJ), you should look into getting one or consult OEMS.
All of what has been written here may be interesting, but it is not helpful. Your ONLY authorities for this situation, because it is governed by state law and regulations, are your state authorities or an attorney licensed to practice in New Jersey. Contact NJOEMS or ask your agency's administration to have a class put on for you by a qualified instructor. Otherwise.....potential trouble.

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