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.

 Thank you for your question. It is a confusing area of practice. The short, straight forward, policy answer is that paramedics provide resuscitation procedures to everyone who requires them UNLESS the patient has a signed Ministry of Health / Fire Marshall approved DNR form indicating there is a DNR plan in place or there is a signed inter-facility DNR order. If the form is not available to be checked then resuscitative measures should be started until the form is produced.

While we wish to follow a persons wishes regarding their end of life, the dilemma is that resuscitation in cardiac arrest is a time sensitive situation. The default expectation is to begin resuscitation if someone calls 911 and requests assistance. A paramedic does not have the luxury of spending time to sort out what the persons wishes are, who is the designated alternate decision maker is if the person is not capable of indicating their own wishes etc.

As you correctly point out, the real world is not so clear. People frequently dont discuss their end of life wishes. When they do, they often dont write down their wishes.  They seldom do so on an approved form. Likely the person or their family doesnt know such a form exists.  The form requires substantial effort to obtain.

The problem is what to do; when the form does not exist, when it cant be readily produced, or when a family member is clearly stating the person does not want resuscitation. It is tempting to follow the direction of the family member but this action does not comply with the standard.

We suggest the following compromise. If an approved form is not readily produced to examine and bystanders indicate the patient does not wish resuscitation then CPR or other resuscitative measures should begin. One of the paramedics should obtain the details and explain that they are obliged to begin until the situation is clarified. This information should be relayed in a patch to the Base Hospital physician and discussed. In most cases the paramedic will be given a cease resuscitation order and the resuscitation can be stopped.

While this is not an ideal solution, this course of action balances the legal obligations and moral claims to respect the autonomy and wishes of the patient. Everyone should be encouraged to discuss their end of life wishes with their family and to document their wishes appropriately.

Cardiac/Circulation,DNR,Medical Cardiac Arrest,Miscellaneous

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