It is customary medical practice to assume that CPR is performed on all persons found to be in cardiac arrest, in the absence of directives from a primary physician to withhold such action. There are individuals who would decline these therapies or for whom the treatments are without benefit. Such persons may legally and ethically decline these treatments. Since in many cases there is prior knowledge that these services are not wanted or not indicated, the Do-Not-Resuscitate (DNR) or "No CPR" order has been used to implement the decision that CPR is not to be performed.
The decision to withhold CPR rests with the patient and his or her physician. These recommendations are intended to improve communication of the existence of a DNR order between the physician and the emergency medical personnel who may be summoned in the event of an emergency.
Additional discussion about the use of directives to limit life-extending medical care may be found in Deciding to Forgo Life Sustaining Medical Treatment, 1983, U.S. Government Printing Office and authored by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Standards for CPR and ECC (JAMA, October 28, 1992, Vol. 268, No. 16), policies of the Minnesota Medical Association (MN Medicine, Vol. 69, February 1986, p. 12-14), The Hastings Center Guidelines; (Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, p. 32., Hastings Center, Briarcliff Manor, NY 1988) and the recent Joint Committee on Accreditation of Health Care Organizations. (JCAHO.) MA1.4.11. Accreditation Manual for Hospitals, 1988).
Willmar Ambulance Service recognizes a patient's right to refuse treatment as stated in the Patient's Bill of Rights (MN Stat. 144.651) and the responsibility of medical personnel to withhold treatments that have no medical benefit.
Do-Not-Resuscitate (DNR, No Code, No CPR): In the event of an acute cardiopulmonary arrest, no cardiopulmonary resuscitation will be initiated.
This order means that prehospital personnel will not initiate or continue cardiopulmonary resuscitation on a patient in cardiac arrest once a valid DNRorder is identified. DNR does not mean that the medical care of any other medical condition will be changed or limited.
A. Physician Responsibilities
The physician is responsible for obtaining DNRforms from the Community Health Department, hospice program, nursing agency or long term care facility. The physician is responsible for discussing with the patient and/or family the indications for withholding CPR and explaining the meaning of the DNR order to the individuals involved. The physician should document this discussion in the medical record and ensure that the DNR form is properly completed with the necessary signatures.
The physician should keep one copy in the permanent medical record and give the original to the patient. The physician is responsible for obtaining consent or providing informed disclosure for the DNRorder in a manner that conforms with the legal, medical and ethical standards of care. The physician must ensure that proxies, signing request forms on the patient's behalf, do so in a manner that conforms to legal and ethical principles applying to proxy decision making.
The physician is responsible for ensuring that the permanent medical record describes the indications, rationale, and involvement of patients (or proxies) in these decisions in a manner that conforms with legal, ethical and medical standards of care.
B. Ambulance Service Responsibilities
Willmar Ambulance Service will operate in accordance with this protocol to allow prehospital personnel to honor the DNRorders.
The recommended paramedic protocol is as follows:
Do-Not-Resuscitate (DNR) orders are orders issued by a patient's physician to refrain from initiating cardiopulmonary resuscitative measures in the event of an acute cardiopulmonary arrest. DNR orders are compatible with maximum therapeutic care and the patient may receive vigorous support (IV, drugs, antishock trousers) up until the point of cardiac or respiratory arrest. DNR orders are valid when the DNR form is properly completed. The DNR form must be signed by the patient/proxy, witness and physician and dated. In the nursing home, DNR orders written in the order section of the medical record are valid if signed by the physician (A DNR form may be used, but is not required in the nursing home.). In the event of uncertainty, resuscitative measures should be initiated.
C. Patient Responsibilities and Rights
A patient has the right to refuse cardiopulmonary resuscitation. The patient should be involved to the greatest degree possible in the decision-making process. Patients are encouraged to discuss these decisions with family members, if appropriate.
When the decision to forego resuscitation is reached between the patient and their physician, a DNRform should be completed, signed and dated by the patient/proxy, physician and witness, or the order should be written in the order section of the medical chart (if one is available), signed by the physician.
The patient, family members or supervising health care agency should keep the form in a readily accessible location or make its presence known during the provision of emergency medical services in the home.
The patient may revoke the decision at any time by destroying the form or
informing prehospital providers or family members of their wish for
cardiopulmonary resuscitation (CPR) in the event of cardiac arrest.
Responsibilities of Health Care Providers Involved in Caring for Patients with DNROrders (Nursing Homes, Home Hospice, Home Health Care).
1. Nursing Homes/Long Term Care Facilities:
Willmar Ambulance Service recommends that nursing facilities develop policies and guidelines regarding the writing, implementation and transmission of the DNRorder during emergency care. Such guidelines should include consideration of the DNR orders being written in the medical record, signed by the physician and dated.
Willmar Ambulance Service recommends the use of the standard DNRform in the nursing facility; however, a written order in the medical record is sufficient to transmit the DNR order to paramedics responding to a long-term care facility.
2. Procedural Standards for Home DNROrders:
DNR orders become effective on the day the DNR request form is signed by the patient or acceptable proxy, the physician and the witness.
DNR orders will remain in effect indefinitely. These orders should be reviewed periodically. Home health care providers supervising the care of patients with DNR orders in private homes are strongly urged to develop policies or guidelines to encourage the proper and safe implementation of this order by medical personnel. Such guidelines may include:
a. Accountability to proper decision-making principles (including the principle of patient involvement in these decisions).
b. Documentation of the rationale for these orders in the medical record by the patient's physician.
c. Procedural requirements for these orders, including regular home surveillance, to ensure that these orders are readily accessible to prehospital personnel.
d. Periodic review of the DNRorder. Health care providers should attempt to ensure that patients and families understand the implementation and recision of DNR orders.
When prehospital emergency medical personnel arrive, the family, patient or staff should immediately present the resuscitation guidelines form. Until properly completed orders are presented, prehospital personnel will assume that no valid DNRorders exist and proceed with standing orders for resuscitation as medically indicated under medical control.
The DNR order may be rejected and overridden if prehospital personnel have substantive reason to believe the order is invalid or in cases of unusual, suspicious or unnatural causes of cardiac arrest. In the event a patient changes his/her mind regarding the DNR order prior to cardiac arrest or family members request resuscitation or disagreement occurs at the time of cardiac arrest, resuscitative measures should be initiated by prehospital personnel and treatment decisions should be made by the physician responsible for care.
Telephone DNRorders will not be accepted by paramedics. Paramedics will not honor DNR orders if they are not legible or properly signed and dated or alternative wording is used to limit medical care, e.g., Health Care Directives, Living Wills, Supportive Care Plans (Paramedics will not interpret Health Care Directives or Living Wills during the provision of emergency medical care).
Physicians present at the scene that are willing to take responsibility for the emergency medical care may verbally give orders to prehospital personnel to withhold or discontinue resuscitation. This must be documented on the ambulance report form with the physician's signature, name, address and office telephone number.
DNR orders may be revoked at any time by the patient who, by destroying the request form, will prevent implementation of the DNR order. The patient is responsible for informing his/her physician and the agency supervising care, if any, of this decision.
Patients with DNRorders remain appropriate candidates for emergency evaluation, assistance, treatment and transport. The 911 emergency number may still be used to summon emergency assistance for such patients who are suffering medical emergencies.
The medical urgency of cardiac arrest precludes prehospital emergency medical personnel from evaluating the propriety of the decision-making processes or administrative procedures used to develop the DNRorder. These personnel will not assume any responsibility for such an evaluation. This responsibility rests with the attending physician and the licensed health care provider supervising care.
The physicians and ambulance services will make every effort to permit patients accessing emergency medical care and transportation to decline unwanted CPR in a manner consistent with the standard of medical care. The ambulance services will continue under the presumption that patients are eligible for and desire emergency medical services. This system is established to permit patients the right to refuse unwanted CPR with the realization that this presumption and the urgency of resuscitation may mean that questionable orders may not be honored.
This guideline is intended for patients receiving fully supervised medical care who might be expected to suffer cardiac or respiratory failure in the near future.
It is not the intent of the ambulance service to dictate policy or require services from long-term care or home health agencies or personal physicians. The ambulance services will assume no responsibility for auditing the internal practices of physicians or any agency supervising medical care with regard to the DNR order.
See Rice Memorial Hospital DNRForm, next two pages. Rice DNR forms may be obtained directly from Rice Hospital care management or Hospice Departments.