Frequently Asked Questions re: DNR's
|Bureau of EMS Policy Statement|
|Policy Statement #||99-10|
|Subject||Re: Frequently Asked Questions re: DNR's|
The purpose of this statement and the frequently asked questions (FAQ) is to provide pre-hospital providers with clarification and information on accepting non-hospital and hospital Do Not Resuscitate Orders (DNR). Readers are referred to PHL § 29-B and DOH Memo 92-32, DNR Orders that are the governing documents for detailed discussions on the subject. This policy does not supercede any other DOH document.
These guidelines are intended to assist local emergency medical services (EMS) agencies in developing DNR policies. EMS agencies should develop policies that instruct crews how to properly respond to patients who have a DNR. DNR policies allowing patients to refuse resuscitation ensure that patient's legal rights are honored and are a critical part of the healthcare and EMS systems. Patients must be provided their legal and ethical rights to consent to or refuse medical care in the prehospital setting. DNR patients are generally, although not always, victims of terminal illnesses, and are encountered in skilled nursing facilities, private residences and other settings. They may or may not be clients of hospices. In some cases, patients use the EMS system solely to obtain medical transportation. In other cases accident victims may present a DNR order.
Despite instructions not to perform resuscitation or call an ambulance, family members and employees of nursing facilities frequently activate 9-1-1 when death is imminent.
In addition to providing palliative care for patients, prehospital care providers may benefit families by assisting in determining when death has occurred. This may be an appropriate role for the EMS system although it should be restricted to private residences and not to licensed facilities which are expected to have policies for determining death by house medical staff.
EMS agencies are encouraged to meet with all components (hospitals, nursing facilities, hospices, etc.) of the health care system in their community in order to develop common understandings and policies to mutually manage patients with DNRs in emergency situations.
What is an "Out of Hospital" DNR?
The New York State Department of Health has an approved standard Out of Hospital DNR form that is legally recognized statewide for DNR requests occurring outside of Article 28 licensed facilities. This form is intended for patients not originating from a hospital or nursing home. The form (DOH-3474) is available on the Department's web site ( www.health.state.ny.us ) or from your local DOH EMS Office or health department. There are NO other approved Out of Hospital DNR forms. Copies can be kept on ambulances and made available to patients, facilities or physicians as a part of their community education program.
What is a recognized DNR Bracelet?
A standard DOH approved metal bracelet, worn by the patient, which includes a caduceus and the words "Do Not Resuscitate". EMT's should assume that a DNR order is in place authorizing the bracelet. It is not necessary to locate the written DNR order.
Where/When is an Out of Hospital DNR Order Valid?
For any patient NOT originating from a hospital or nursing facility including but not limited to:
- The patient's home
- A hospice
- A clinic
What determines the validity of the Out of Hospital DNR?
- Merely the presentation of a signed Out of Hospital DNR form (or a copy) or a DNR bracelet to the EMT.
- A good faith attempt to identify the patient. A witness who can reliably identify the patient is useful.
- Out of hospital DNRs do not expire.
- The Out of Hospital DNR form and/or bracelet should be taken with the patient.
Hospital & Nursing Home DNR orders
All Article 28 licensed facilities are required to issue, review and maintain DNR orders. EMS providers will honor hospital DNR orders for patient transports originating from the facility. The DNR can not be expired. The facility staff must provide a copy of the order and/or patient's chart with the recorded DNR order to the ambulance crew. Facilities, other than hospitals or nursing homes, are encouraged to use the NYS-DOH approved non-hospital DNR Form as supplemental documentation to avoid confusion and potentially unwanted resuscitation.
May EMS providers accept living wills or health care proxies?
A living will or health care proxy is NOT valid in the prehospital setting.
Under what circumstances may an EMS provider disregard an Out of Hospital DNR order?
- Any case where there is reasonable evidence to suggest that the DNR order has been revoked or cancelled.
- If the patient is conscious and states that they wish resuscitative measures, the DNR Form should be ignored.
- If the patient is unable to state his or her desire and a family member is present and requests resuscitative measures for the patient and a confrontational situation is likely to result, if the request is denied.
- A physician directs that the order be disregarded.
What procedures are and are not preformed if the patient presents a DNR?
- Do not resuscitate (DNR) means, for the patient in cardiac or respiratory arrest, NO chest compressions, ventilation, defibrillation, endotracheal intubation, or medications.
- 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.
- Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped, ventilation should not be assisted.
- CPR must be initiated if no Out of Hospital or facility DNR is presented. If a DNR order is presented after CPR has been started, stop CPR.
- For unusual situations or questions on individual patient circumstances, contact medical control.
What documentation is required for a patient with a DNR order?
- Emergency medical technicians/paramedics should attach a copy of the Out of Hospital DNR form, hospital DNR order and/or copy of the patient's chart to the patient care report, along with all other usual documentation. It should be noted on the patient care report that a written DNR order was present including the name of the physician, date signed and other appropriate information.
- If the cardiac/respiratory arrest occurred during transport, the DNR Form should accompany the patient so that it may be incorporated into the medical record at the receiving facility.
- Patients who are identified as dead at the scene need not be transported by ambulance, however, local EMS agencies should consider transportation for DNR patients who collapse in public locations. In these cases it may be necessary to transport the individual to a hospital without resuscitative measures in order to move the body to a location that provides privacy. Local policies need to be coordinated with the Medical Examiner/Coroner and law enforcement.
PHL Section 2977.12 "No person shall be subjected to criminal prosecution or civil liability, or be deemed to have engaged in unprofessional conduct, for honoring reasonably and in good faith pursuant to this section a non hospital order not to resuscitate, for disregarding a non hospital order pursuant to section ten of this section, or for other actions taken reasonably and in good faith pursuant to this section".