Do Not Resuscitate Orders and You

Also posted at Star of Life Law.

This post was generated from an email I received from Mark over at Medic999. One of Mark's readers posted the details of a call he ran wherein the patient had a valid DNR order, and he was uncomfortable with the way the the DNR limited the available treatment options. You can visit Mark's blog for a full run down of the opinions there.

For the readers outside of the United States, you should be aware that each State sets its own laws and regulations regarding DNR orders; there is no nationwide standard. Each State's law may be different.

First a bit of a disclaimer: I am educated in United States common law and most specifically educated in the law of South Carolina, the State of my bar admission. I am also registered as a NREMT-P in South Carolina so I am most familiar with South Carolina’s laws on DNR orders.

I will focus first on the law within the jurisdiction I practice law and ride an ALS truck. I will then discuss my thoughts as to the call posted by Matt, and will end with a sampling of DNR regulations from other States for comparison.

Here in South Carolina we have the Emergency Medical Services Do Not Resuscitate Order Act. To establish a DNR order in South Carolina, the patient must: (1) have a terminal condition; and (2) the terminal condition must have been diagnosed by a health care provider and the health care provider's record establishes the time, date, and medical condition which gives rise to the diagnosis of a terminal condition. Thus, it is a pre-requisite to have a physician established terminal condition.

When EMS personnel are presented with a valid DNR order EMS personnel must not use any resuscitative treatment. EMS personnel must provide that degree of palliative care called for under the circumstances which exist at the time treatment is rendered.

Okay, that is some great lawyer-speak, but what constitutes the “resuscitative treatment” we can’t give, and what does “that degree of palliative care called for under the circumstances which exist at the time treatment is rendered” mean for those of us in the street?

For that guidance we must consult South Carolina Department of Health and Environmental Control Regulation 61-7, Sections 1406 and 1407. In the event that the patient has a valid DNR order, the following procedures shall be withheld or withdrawn: (1) CPR; (2) Endotracheal intubation and other advanced airway management; (3) Artificial ventilation; (4) Defibrillation; (5) Cardiac resuscitation medication; and (6) Cardiac diagnostic monitoring. These 6 items are defined as prohibitive resuscitative treatment in the presence of a valid DNR order.

The following treatments may be provided as appropriate to patients who have executed a valid DNR order: (1) Suction; (2) Oxygen; (3) Pain medication; (4) Non-cardiac resuscitation medication; (5) Assistance in the maintenance of an open airway as long as such assistance does not include intubation or advanced airway management; (6) Control of bleeding; and (7) Comfort care. These 7 items are defined as the permissible palliative measures that can be given in the presence of a valid DNR order.

Okay, so that is what I can do and can’t do in the presence of a valid DNR order. But wait, there is more. When presented with a valid DNR order, I must honor it, regardless of the circumstances. If I can’t or won’t honor it, then I must immediately transfer patient care to another EMS provider or other health care provider who will honor it.

That is the law in the State I work.

Let’s restate Matt’s patient presentation: Elderly male, lungs full of fluid, SpO2 mid to high 60s on a nasal cannula, improved to about 69-70% with a non rebreather, respirations about 24, mental status , about a GCS 5. Nursing home staff states aspiration of vomitus, suction attempted with no relief. Valid DNR presented to EMS on arrival.

If I was presented with the above in my jurisdiction, right off the bat there are several things that I cannot do for this patient in the presence of the valid DNR order. I cannot drop an ET tube, King Airway or LMA. I cannot use a BVM to artificially ventilate. I cannot attach my LifePak 12 for cardiac monitoring.

My patient revoked my ability to use these tools, and I will respect their decision, but I won’t just watch them circle the drain. There are things I can do that may really help this patient. First, I will do my own assessment, as I do not trust NH assessments. I can still suction, so I would try to clear the airway as best I can. Here, an OPA is a basic skill, so dropping an OPA to maintain an open airway would be permitted. I can administer oxygen via non-rebreather over the OPA. (A tougher question would be whether CPAP or BiPAP is considered artificial respiration. I’ll punt on that one for now.)

I can also establish an IV and check a BGL. Who knows, maybe his blood glucose is 20 and an amp of D50 perks him up. I can…well, you get the idea. There are things we can do and should do to care for our patients.

I encourage you to become familiar with your State's laws and regulations regarding DNR orders and your local protocols on DNR orders so that when presented with a valid DNR order you know what you can and can't do to care for your patient.

These are tough situations for us because we are used to doing all we can with all we got. But we must remember that our primary purpose is quality patient care, and sometimes that means respecting our patient’s wishes regarding the end of life too.

Other State DNR order regulations for comparison:

State of California

State of North Carolina

State of Texas