Can you do chest thrusts on someone who is unresponsive with a DNR?

Can you assist ventilations when a patient has a DNR? I had a call recently where a patient had a DNR, she was GCS 6, breathing spontaneously at a rate of 20 but there was very little air movement and an O2 sat in the low 80’s after we put her on a high concentration mask. I decided it was appropriate to assist her ventilations with a BVM to try to push oxygen deeper in her lungs. This did seem to help because when we arrived at the hospital she was now opening her eyes spontaneously, had a GCS of 10 and her O2 sats got to low 90’s. I just want to clarify the difference between assisted ventilations and using a BVM for resuscitation when it comes to DNR’s.

can you insert an OPA in an old person

Question: Are paramedics in Ontario authorized to adhere to a person’s DNR wishes documented on a completed ‘CCAC Plan of Treatment’ as an alternative to a completed ‘DNR Confirmation Form?

Question: When the Ministry of Health’s DNR forms are filled out, can the section where the patient’s name goes have a sticker from the hospital with the patients name/health card #/DOB, etc. instead of having the name printed or does that make the form invalid. The form specifically states the patients name should be printed clearly. I wasn’t sure if the ID sticker was something we could accept instead or if that section can only be filled out by hand.

Question: How is the DNR standard in the BLS PCS reconciled with this statement in the ALS PCS: “if a paramedic is aware or is made aware that the person has a prior capable wish with respect to treatment, they must respect that wish (for example, if the person does not wish to be resuscitated).”

Obviously the ideal situation is that the patient has the DNR confirmation form and there are no issues. The issue comes up with regards to verbal DNRs issued by a capable patient or SDM (that are reasonable), or in such cases where the patient has a DNR, living will or other advanced directive that specifies the patients wishes, but no prehospital DNR form. Is this form not redundant provided there is a reasonable indication that the patient does not wish to be resuscitated or have aggressive life sustaining therapies delivered?

How can the BLS PCS DNR standard be reconciled with the ALS PCS regarding honouring a prior capable wish when the provider is made aware of such wish (provided its reasonable)? Especially given that in nearly ever other case, a directive in the ALS PCS over-rides the BLS-PCS. Given that this issue is not nearly as cut and dry in reality, or in any other healthcare setting, as it seems to be made out to be in EMS in this province what is the situation with regards to this? Especially given that end-of-life issues are increasingly common, the issue is not going to disappear. There are many other provinces that use a similar wording or philosophy to that mentioned in the ALS-PCS under consent and capacity.

Question: Are we allowed to accept photocopied DNR? I have heard several discrepancies on this question.

Question: I have been to a few calls where the patient does not have a DNR, but the death is expected and family does not want CPR or other interventions. The family will make statements like “we don’t want CPR” or they wouldn’t want CPR”, etc. Do we initiate the CPR and Defibrillation protocols until we can get hold of the BHP or do we run the call and transport regardless of family request?

Question: There is some confusion about patients that have a valid DNR, and are very sick requiring transport. It makes sense that many of the ACP skills might not be utilized on these patients, and CPAP would be a PCP skill. There are cases where the family changes their mind on a DNR, and cases where the status is not clear. There are also other cases where a patient may be a trauma and have a valid DNR where they may need a needle decompression, but not necessarily cardiac arrest needing CPR or intubation. Is it OK for ACPs not to attend valid DNR patients?

Question: I was told by a physician that a DNR becomes void with a suicide attempt. I was wondering how we should approach this situation.

Question: I was just wondering if we have a patient with a valid DNR are we still allowed to Bolus if they fit our protocol or is this considered an advanced life saving technique?

Question: I had a call today to a nursing home where the patient had a valid DNR. The patient was in agonal respirations. The staff stated the patient HAD to be transported to ER as per direct orders from the doctor on call for the nursing home. She kept saying the patient was a level 3 and he had to go to ER. My partner and I told the staff we cannot do anything for him and with a valid DNR the patient does not need to be transported. The staff argued with us more saying the patient had to go and that they already called ER. Instead of getting into it further with staff my partner and I loaded the patient and went to ER. We transported Code 3 as the patient expired as soon and we left for ER. Were we right in doing so? I pre alerted ER about the situation and they were accommodating when we got there.

Question: This question is regarding not giving Narcan to a DNR patient. Obviously, if there is not an underlining medical issue (e.g. terminal CA) and a patient ODs, even with a DNR, we attempt to reverse any issues. However, if the patient does have a medical issue with a DNR, has decided to OD to commit suicide and is in a pre-arrest / arrested state, is it reasonable to assume that since they are breaking the law, that the DNR can no longer be valid?

Question: If a patient meets the protocol for having CPAP treatment but they have a valid DNR Confirmation Form can a PCP still administer CPAP?

Question: If a patient has a valid DNR, can they still fall under the Stroke Protocol? I realize the protocol’s contraindications list a palliative patient or terminally ill but does not address DNR. DNR in my point of view only applies to a patient who is dead, and wishes to not be resuscitated. Treatment for stroke at a proper facility could restore the patient’s quality of life if such is affected by the stroke, and I feel they should still be included. I just wanted to verify.

Question: On a recent call, we transported a patient from a nursing home with a valid MOHLTC DNR. In the middle of all the paperwork was a nursing home DNR with level 1, level 2, and there was a check mark that the patient did not want to decide on a DNR status at this time. The MOHLTC DNR was dated in 2009 and the nursing home DNR was dated 2010. Do we respect the valid MOHLTC DNR or the nursing home DNR dated later?

Question: Just some clarification in regards to DNR’s. If a patient is having an episode of an exacerbated Asthma and has a valid DNR, do we administer Epi for the asthma? I understand that we cannot “bag” the Patient due to the DNR status.

Question: A patient requires assisted ventilations via BVM for shortness of breath for CHF or for exacerbated asthma, can we assisted ventilations for this patient. I understand that we cannot perform artificial respirations for a patient who is apneic, but can we assist ventilations with a patient who is conscious and breathing on their own, but needs assistance? Patient has a valid DNR.

Question: I have recently received an ACR audit, and have spoken to others, within my service, who have received audits as well, stating that a DNR patient who has not arrested should be ventilated via BVM. Everyone is under the impression that a DNR patient should not be bagged. I know that I have had previous conversations with SWORBHP educators in which the final word on this subject had been no BVM in the presence of a DNR irregardless of whether then patient was VSA or pre-arrest. A similar question on this issue was previously asked and answered on 1-March-2012 with the resulting answer being “therefore, to answer your question, if a valid DNR form is available, none of these “advanced cardiopulmonary resuscitation” procedures should be initiated, period. The SWORBHP medical directors would suggest that this is independent of whether or not the patient has completely arrested or not”. The question now is what is the right thing to do? What we have previously been told is right or what the auditors are now saying we should be doing? Could you please shed some light on the situation because there’s once again a lot of confusion surrounding the correct application of the DNR. Thanks.

Question: This question is a follow-up to clarify between two questions previously asked- specifically, regarding advanced resuscitation in the setting of DNR, and treatment of FBAO in the setting of DNR. In the most recent question the DNR validity form is quoted as stating that chest compressions should not be initiated on patients with a valid DNR, while in the earlier question it was stated that DNR does not preclude treatment for choking. Should we come across this situation, would we then only administer ‘Heimlich’-like abdominal thrusts and not proceed to chest compressions when the patient goes unresponsive, or should chest compressions be initiated until the heart has arrested and then discontinued (i.e. not proceeding to true CPR)?

Question: If a DNR only comes into play once the patient has suffered respiratory or cardiac arrest, why do hospitals use DNR as an excuse to downgrade CTAS or justify putting certain patients as a code 7?

Question: The DNR confirmation form states the paramedic will not initiate basic or advanced CPR such as, TCP being one of them. From what I understand, until that person suffers cardiac or respiratory arrest, they are fair game for treatment. So, if a patient is in a 3rd degree block at 20bpm and they have a DNR, we are pacing this patient?

Also, what do they mean on the DNR confirmation form about palliative care? They say we are to provide care to alleviate pain/discomfort such as – NTG, ASA, benzodiazepine, epi for anaphylaxis, o2, Morphine etc. Is this merely an FYI on how to treat a pre-code patient? Clearly the patient would have to be alive to administer these drugs. Again it is said that the DNR does not come into play unless the patient codes. Why is this on the form?

Question: Can you explain what this part in the consent section means? It seems to give more flexibility to not begin resuscitation based on family members who seem reliable saying that that is what the patient wanted. “If a paramedic is aware or is made aware that the person has a prior capable wish with respect to treatment, they must respect that wish (for example, if the person does not wish to be resuscitated).”

Question: Called to a nursing home for 90 year old male. On scene staff state patient has valid DNR but they are unable to produce it. The crew continues to resuscitate patient as per usual. Enroute to receiving facility, CACC advises the crew that family has phoned in and stated that they have the DNR and they do not want the patient resuscitated. The attendant phones the attending BHP and advises him of the situation. The BHP orders EMS to cease resuscitation efforts on patient. Is this right or wrong?

Question: Patient has a FBAO and a valid DNR (ex. nursing home). Resuscitate or not?