DNR'S

[Guest cheekmedic]

Ok, I am going to open the flood gates, when honoring DNR's 9 provided that it is a valid out of hospital dnr), do you intubate or do you not intubate? This is a hot topic right now, and there are equally convincing arguments to either side of it! just wanted to get everyones opinion!

Stay Safe Out There!

[Guest]

What it means is "DO NOT RESUSCITATE" duh!!!!!!!!!!!!!!!!!! :twisted: :twisted: :twisted: :twisted:

[MGMedic 0]

Pretty much what he said.

[JM15 386]

yeah

[Guest cheekmedic]

First let me state that I am well aware of what a DNR consists of. I happen to be in complete agreement with honoring the DNR, provided its valid and treating the patient enough to make them comfortable while at the same time honoring their wishes. this includes not intubating them.

That being said, their is an argument being made that a DNR does not take effect until a person has officially expired, meaing no heartbeat and obviously no spontaneous respirations. As stated previously, the question came up ( not by me),So I figured I would pass it along, to get some other points of view.

Stay Safe

[x635 4,066]

Great topic! I feel this is a tremendous grey area. DNR does NOT mean "Do Not Rescuscite". Unfortuntely, it is not that simple? What level of care are you supposed to provide to the patient, and where are you supposed to cut it off? If they patient has a DNR and is going into resp arrest, are you not supposed to bag them? This has me confused and bewildered, as there are so many different storys swirling around. I'd love to see REMSCO come out with a meeting or clear policy update so we all stand on the same page.

[WAS967 97]

What it means is "DO NOT RESUSCITATE" duh!!!!!!!!!!!!!!!!!!

Thanks for that uninformative post. Unfortunatly it does nothing to contribute to the thread. I was going to delete it but since future posts alude to it I'll let it stand. In the mean time:

This topic is what I was getting at with the Scenario of the month. Cheeky peaked my interest when we discussed just this while at work the other day. Here is what I found:

http://www.health.state.ny.us/nysdoh/ems/p...olicy/99-10.htm

To quote: "If the patient is NOT in cardiac or respiratory arrest, full treatment for all injuries, pain, difficult or insufficient breathing, hemorrhage and/or other medical conditions must be provided."

This implies that intubation IS included in the treatment that should be provided. If you are in a situation where a patient needs to be intubated and they have a DNR I understand it becomes a huge moral obligation. If a patient is breathing inadequately and they need to be intubated/bagged then so be it. Periodically stop and see if they are still breathing spontaneously. If they are not, then you stop bagging as the DNR now stands.

Another quote also comes in handy here: "For unusual situations or questions on individual patient circumstances, contact medical control."

I have no doubt that eventually we'll run across an irate family member that would fight you if you were to try and intubate thier family member with a DNR. Obviously scene safety comes into play. But for the moral judgement/best interest of the patient I'd talk to the doctor and see if they are willing to grant you the ability to "let them go".

[WAS967 97]

Great topic! I feel this is a tremendous grey area.

I used to think so too until Cheek spurred my interest in the subject and I looked it up. The FAQ actually makes it rather clear.

DNR does NOT mean "Do Not Rescuscite".

Did you perhaps mean that it doesn't mean "do not treat"?

Unfortuntely, it is not that simple? What level of care are you supposed to provide to the patient, and where are you supposed to cut it off?

Any and all care that you would provide if the patient did not have a DNR. Care stops when breathing/circulation stops.

If they patient has a DNR and is going into resp arrest, are you not supposed to bag them?

If resps are failing....ie....agonal with pulse, then you assist and intubate. If they are absent you stop. If resps are agonal with no pulse, you stop.

This has me confused and bewildered, as there are so many different storys swirling around. I'd love to see REMSCO come out with a meeting or clear policy update so we all stand on the same page.

REMSCO won't need to since the policy is dicated by the state. I'm a little bewildered more so on the side of ethics more than policy. The policy seems clear cut. Does it seem right? Not if you ask me. I'd be inclined to agree with mark that if a patient has a DNR and family states the patient does not want to be intubated, then we should follow the patient's wishes. Unfortunatly the state policy does not afford us that latitude directly. I'd defer to medical control since it ultimatly falls on them. I know too that the first time we bring in a DNR patient intubated the ER staff will probably blow a gasket.

I look back on a call that was done at WAS in Elmsford back in the day. Perhaps a Slepy job. One of our medics intubated a DNR patient and made it clear that it was for airway control more than to keep the patient breathing (patient was breathing on thier own). Back then I thought he was wrong. In retrospect, i think he acted approriately.

As the issue of DNRs, DNIs, etc, become more and more complex, with cases like Terri Schiavo in the news, I think New York State needs to reevaluate it's DNR policy and perhaps expand the Out of Hospital DNR form to include limitations of care (no intubation, allow defibrillation, no cardiac medications. etc).

[Guest alsfirefighter]

DNR's are always a good convo at the table. I treat everyone who needs it. When all else fails, again you fall back to medical control. I have had to explain to the family that the DNR is only valid for a patient that isn't breathing and does not have a heart beat. Many do not understand.

How about the fact that we only honor DNR's and not living wills or advanced directives. Anyone been caught up in that mess several times? The bottom line is you always do what is best for the patient and often a very well spoken and professional explanation will do you best with family members in that situation.

[ems-buff 81]

DNR mean DO NOT RESUSCITATE

not DO NOT TREAT

that all i have to said on the subject

[WAS967 97]

DNR mean DO NOT RESUSCITATE

not DO NOT TREAT

that all i have to said on the subject

The problem is, the issue isn't that simple. The policy from the state is very straight forward but unfortunatly many of the situations that we encounter that are related are not. ALS said it well. Some of these calls may require a lot of calm explaination to people who otherwise just don't know what is going on or why we do what we do.