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?

 Thanks for the terrific question. The DNR standard has been a source of many frequently asked questions, and we are pleased that we may be able to clarify a few concerns through this forum.

It is essential that you review the DNR Confirmation Form. It can be found here: http://www.lhsc.on.ca/About_Us/Base_Hospital_Program/Education/EHS_Training_Bulletins.htm

The actual DNR standard itself speaks of "a person who has suffered respiratory or cardiorespiratory arrest" on many occasions. The standard directs paramedic practice "with respect to the management of situations where a patient.....has expressed the wish not to be resuscitated in the event that they experience a respiratory or cardiorespiratory arrest" No doubt this is where the confusion comes in.

Ironically, on the actual DNR confirmation form itself, nowhere does it state that a cardiac arrest must have occurred. Careful review of Part 1 of the form will show that the definition of "do not resuscitate" includes "advanced cardiopulmonary resuscitation (CPR)" which is defined as: chest compression, defibrillation, artificial ventilation, insertion of a OPA or NPA, endotracheal intubation, transcutaneous pacing, and advanced resuscitation drugs such as vasopressors, antiarrythmic agents and opioid antagonists.

Clearly, some of these procedures (such as pacing as you describe) would not be used exclusively for a patient who has suffered a cardiac arrest. As you know, pacing most often is for profoundly bradycardic patients who have not yet suffered a complete "cardiorespiratory arrest", yet are found to be tremendously unstable and hypotensive.

Therefore, to answer your question, if a valid DNR Confirmation 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 the patient has completely arrested or not.

Think of it this way: if a patient is in a pre-arrested state, is tremendously unstable, or has suffered a cardiorespiratory arrest, and one of these listed procedures would be indicated, they should not be performed by the paramedic as the patient has specifically requested this course of conservative action.

Consider the following situation€¦.if a patient has a signed and valid DNR Confirmation form, and had a decreased LOC with oxygen saturations of 60% despite 100% FIO2, but had a perfusing rhythm and blood pressure, this patient should not be intubated.

To answer the second part of your question, those interventions or therapies listed in Part 2 are considered necessary to provide comfort or alleviate pain and therefore should be provided where indicated by your directives. THis section was included to specifically reinforce that depite a patient having a valid DNR confirmation form, certain medications and procedures are acceptable- specifically if the goal is to maintain patient comfort. You are correct in your assertion that clearly the patient would have to be alive to administer these drugs, and this lends further credibility to the SWORBHP Medical Directors interpretation that this form should be followed by the paramedic regardless of whether the patient has completely arrested or not.

Hope this clarifies things.

Bottom line, think of the DNR confirmation form as list of specific patient instructions of how they wish to be treated when they become extremely unwell or have arrested and they are unable to communicate for themselves.

DNR,Miscellaneous

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