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?
Thanks for the excellent question. There are many other ASK MACs which deal with interventions and DNR.
A link to the DNR Standard can be found on our website here:www.lhsc.on.ca/About_Us/Base_Hospital_Program/No.108V.1.0DNRStandard.pdf
It is difficult to envision every scenario. The CTAS level and sickness level of the patient should be the guide as to the responsibilities of the attending medic as it would be in any other case regardless of DNR status. Indeed these patients may have a stroke, trauma, or other medical condition that may benefit from more advanced skills. There is also the possibility of utilizing narcotic pain medication for compassionate palliative care. A change in the DNR status by attending family members may also be more easily dealt with, although hopefully this will be very infrequent with better communication surrounding the DNR process.
To the specific question of ACPs responsibilities in these cases, I would direct you to updated policy on PCP ACP crew configuration from April 2014.
Basically, when considering crew attendance and responsibilities these cases should be approached exactly the same as any other case depending upon the clinical situation and judgement of the crew as outlined in the policy. In practice as a guide as we have done for years the ACP will attend on any CTAS 1 or 2 return transport.