Question: We had our recert this week and I have a question about DNR patients. In the pocket book it says that a patient will get epi IM if they have a history of asthma and BVM ventilation is required. So I am wondering, if a DNR patient does not receive a BVM under any circumstance and an asthma patient with a valid DNR who started off just slightly SOB became severe and required a BVM would they still be eligible for epi? In other words does "required" mean that yes it is required due to the severity of SOB, but due to the fact they have a DNR they don't actually get the BVM, can they still receive the epi, which is not contraindicated on the DNR validity form? Thanks in advance.

Thanks for your question. Hopefully a severe asthma exacerbation requiring BVM ventilation and therefore epinephrine IM in a patient with a valid DNR is a rare situation.

The DNR confirmation form identifies that epinephrine for anaphylaxis remains indicated for patients with a DNR in section 2 for the purposes of providing comfort (palliative) care. It also stipulates that this list of what is acceptable under section 2 is limited to those interventions and therapies so in theory epinephrine for this scenario is not contraindicated.

Epinephrine as a vasopressor is contraindicated in patients with a DNR as per section 1 however in the clinical scenario you describe above, the patient does not require epinephrine for that indication.

As you have correctly identified, the SWORBHP Medical Council has previously directed that BVM ventilation is contraindicated in DNR patients as this represents artificial ventilations and this as well is listed as contraindicated in section 1 of the DNR form.

Finally, your Bronchocontriction Medical Directive does indicate that BVM ventilation is required for a paramedic to administer epinephrine however one could argue that BVM could be required yet not provided (since contraindicated by the DNR) thus meeting the indication of "required".

The bottom line for this rare situation would be to NOT administer the epinephrine IM in isolation to a DNR patient requiring BVM ventilation but not receiving it due to limits imposed by a valid DNR. IM Epi for asthma at best is moderately effective and most likely of little benefit as an isolated intervention.

As with any rare situation not explicitly covered by the Medical Directives, patching to the BHP for direction should be considered.

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