Date Published

March 6, 2013

Updated For

ALS PCS Version ALS PCS Version 5.2


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.


 Difficult situation. Thanks for the question. From your example, it appears that your patient had not fully suffered a full respiratory or cardiorespiratory arrest (although it was imminent).

This situation is detailed in the DNR Patient Care Standard on page 11, where it states that if upon paramedic arrival at a scene it is determined that the patient is not experiencing a respiratory or cardiorespiratory arrest, the paramedics will provide palliative care as required in addition to any other assessments and interventions (other than interventions considered part of CPR) necessary until the arrival at the destination. It appears that your patient should have been transported.

We would advise caution as to the different "levels" of DNR as unfortunately they are not standardized provincially, but rather these levels are often individualized at each facility. The MOH form indicating there is a valid DNR is standardized, but the details need to be reviewed on a case by case basis (this is also noted in the DNR Patient Care Standard). Some facilities have a palliative option whereby patients are not be transferred by EMS. In turn, this can be overridden by the treating physician when the patient appears to require more comfort care for palliation. A good example would be a palliative patient with a fracture, which may need fixation for pain control, or bone metastasis requiring radiation therapy.

The DNR Standard also provides direction for how paramedics are to proceed when/if the patient suffers a respiratory or cardiorespiratory arrest prior to arrival of the paramedic crew or during the transport phase.

A copy of this standard can be found on our website here:



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