Scenario of the Month: DNR Patient

[WAS967 97]

Okay. Here's a scenario for everyone. Main goal is to gather input and get people to think. Please just provide an explaination for what you would do in this situation, you may be as brief or verbose as you wish. We'll open the scenario for debate later on so save the critiques of other's answers for then or they will be deleted. Answer as appropriate for your level of certification. Appropriate questions may be asked as necessary.

You are operating as an emergency medical provider in the state of NEW YORK. You respond to a call for an 80 year old female patient who is short of breath. Upon arrival you are shown to the patient by the family who tells you that she has a history of liver cancer with metastases and has a standing DNR order on NYS Form DOH-3474 which is presented to you by the family. You find the patient laying in bed in obvious shortness of breath with congestion audible from across the room. Patients eyes are open but she appears lethargic and just stares blankly. Respirations are labored at a rate of about 40 with heavy accessory muscle usage (intracostal and supersternal retractions). Pulse is rapid, irregular, and thready at a rate of approximately 150 BPM. Skin is Warm and Clammy.

[Guest NYTruckie]

To really answer the question I would need more information. So with the information that I was given, I would give Oxygen, Sit the patient up, start and IV, check her Blood sugar, Given 2 mg narcan, If congestion is ronchi I would give a combivent treatment., and then probably have to intubate the patient.

I would like to know the following info:

Blood Pressure

Skin Tenting?

Skin Temp

Last Meal

Medications

Pupils

How long has she been like this

Any other signs? Positive and/or Negative

DNR is Not Do Not Treat

[WAS967 97]

To really answer the question I would need more information.

No real question, just looking for people's thoughts on treatment modality.

So with the information that I was given, I would give Oxygen, Sit the patient up, start and IV, check her Blood sugar, Given 2 mg narcan, If congestion is ronchi I would give a combivent treatment., and then probably have to intubate the patient.

I would like to know the following info:

Blood Pressure

Lets say 90/60.

Skin Tenting?

None discernable.

Skin Temp

Skin is Warm and Clammy. To touch it seems hyperthermic.

Last Meal

Ate a short while before 911 was called and had an episode of vomiting. Family believes she may have choked on some food for a short period because she is so weak, but it seemed to self resolve with the patient coughing from time to time.

Medications

Well, we could throw anything in here really. But lets say Duragesic and MS Contin for pain, Coumadin and Digoxin for a history of A-Fib (to kind of fit in with the irregular heart rate). Possibly others but the family can't find them. Patient is also on a home oxygen unit with 2lpm supplied by nasal cannulae.

Pupils

Sluggish but reactive and just a hair above pinpoint, say about 2mm.

How long has she been like this

When asked the definition of a "short while ago" the family states patient ate about 2 hours ago, vomited shortly thereafter and was fine for about an hour. Patient then seemed short of breath about 15 minutes prior to calling 911 with persistent cough.

Any other signs? Positive and/or Negative

Lets go with no for now and keep it fairly simple.

DNR is Not Do Not Treat

Good point. But lets throw a stone in the mill. Family (daughter specifically) states she has the patient's living will and it states that the patient wishes not to have any heroric measures taken to lengthen her life, including breathing/feeding tubes, IV hydration/nutrition, defibrillation, etc.

[Guest NYTruckie]

  Good point. But lets throw a stone in the mill. Family (daughter specifically) states she has the patient's living will and it states that the patient wishes not to have any heroric measures taken to lengthen her life, including breathing/feeding tubes, IV hydration/nutrition, defibrillation, etc.

So why was 911 called?

Call M/C and put it on the doctor, it's his/her license you are working under.

[mikeinet 37]

Does the family have a copy of the living will to prove that statment? They provide the DNR according to the senario which I'm guessing is proven legit... but the pt isnt in arrest which a DNR would come into play for...

I was always taught to lean on the side of caution and treat if you don't know - just as if you can't confirm a DNR then you start the compressions.

Just as said: DNR != Do not treat. I'd go ahead and start treatment as with any other pt.

[WAS967 97]

So why was 911 called?

Any number of reasons could arise in this case. Family panic. Main caregiver was out and unreachable and other family did not know what to do so called 911, etc.

Call M/C and put it on the doctor, it's his/her license you are working under.

[WAS967 97]

Does the family have a copy of the living will to prove that statment? They provide the DNR according to the senario which I'm guessing is proven legit... but the pt isnt in arrest which a DNR would come into play for...

Living Will is presented by the daughter and states the aforementioned.

I was always taught to lean on the side of caution and treat if you don't know - just as if you can't confirm a DNR then you start the compressions.

Just as said: DNR != Do not treat. I'd go ahead and start treatment as with any other pt.

What treatment would you provide?

[Guest]

heres what i would do.. i would most likely treat the pt for cardiogenic shock or other, not important. the reasoning is the pt is not in arrest , presenting problem could be unrelated to terminal illness in which the dnr was created. 911 was called. and although this might sound harsh i don't know this person meaning no emotional investment and if for some reason this call produces litigation i'll much rather defend a wrongful life suit than a wrongful death one. peace!

[Guest mediconpatrol]

This is probably a situation that if we havent dealt with yet..we will in the future...

I understand the patient is not in an arrest situation yet and that is where the DNR comes into play...but based on the history you provided and the DNR being present..I would initiate an IV...neb...notify medical control of situation..and assist resp. with BVM....as long as I am able to get a good seal and increase oxygenation...they can deal with the DNR issue at the hospital...

[HCFRFF 0]

Treat the PT not the DNR!

[Eagle24 2]

I take it most of you guys/girls are paramedics...as an EMT-B seems like a load-and-go situation...Obviously an EMT would give O2 and treat for shock...but i mean sitting up the patient, making sure the airway is clear and putting a NRB on isn't "heroic measures"...Personally, I would call ALS, medical control and if they want to decide to give NO TREATMENT based on the situation-that's another story...but right now she does not have to be resuscitated, she has to be treated because we were called to that location by SOME family member...EMT-B's can't put a tube in, or start IV's with meds...so from my perspective it's not really my call...I'm transporting...

Obviously if a family member was confused enough to call 911 because they weren't sure what to do-then that means that they're NOT SURE what to do...they could say one thing, and change their mind the next day and say we didn't do our jobs right. . .I'm sure we've all been told this, but if you have any doubt about whether to treat a pt. or not, do it, it's easier to defend your actions.

BTW-i think this is my first post so i'm very open to feedback-let me know what u guys/girls think...I'm not perfect-I could be looking at this the wrong way

[WAS967 97]

take it most of you guys/girls are paramedics...

There is actually a good mix on the board here. But mosto f the people who have responded so far are medics, yes.

as an EMT-B seems like a load-and-go situation...Obviously an EMT would give O2 and treat for shock...but i mean sitting up the patient, making sure the airway is clear and putting a NRB on isn't "heroic measures"

Would you sit a person upright with a B/P of 90/60?

Would you consider assisting respirations in this patient with a resp rate of 40 and heavy accessory muscle usage?

Personally, I would call ALS, medical control and if they want to decide to give NO TREATMENT based on the situation-that's another story...but right now she does not have to be resuscitated, she has to be treated because we were called to that location by SOME family member...EMT-B's can't put a tube in, or start IV's with meds...so from my perspective it's not really my call...I'm transporting...

It actually IS very much your call. You are in charge. So what if you can't put a tube or a line in place? Medical Control tells you to treat them like any patient and ALS is unavailable. What do you do? Relying on someone else to tell you isn't always an option.

Obviously if a family member was confused enough to call 911 because they weren't sure what to do-then that means that they're NOT SURE what to do...they could say one thing, and change their mind the next day and say we didn't do our jobs right. . .I'm sure we've all been told this, but if you have any doubt about whether to treat a pt. or not, do it, it's easier to defend your actions.

Which do you think is easier to defend: overtreating or undertreating?

BTW-i think this is my first post so i'm very open to feedback-let me know what u guys/girls think...I'm not perfect-I could be looking at this the wrong way

If anyone said they were perfect I wouldn't believe them.

[Eagle24 2]

with a low BP-trendelenburg...assuming med control is aware of the situation as says "treat them as a patient" and ALS unavailable-yeah I'd use a BVM---this might be considered the beginning of "heroic measures", but if it was my call it is DEFINATELY better to overtreat than undertreat given the circumstances...Is is required in new york for EMT-B's to honor the living will? I think DNR orders are the only orders EMT-B's have to follow. I think as long as he is not in cardiac/respiratory distress, as an EMT-B if I made the call, I would treat/trans to be safe...

[WAS967 97]

Is is required in new york for EMT-B's to honor the living will? I think DNR orders are the only orders EMT-B's have to follow.

You are correct. And it applies to any prehospital provider: A living will or health care proxy is NOT valid in the prehospital setting.