Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

A Spoken DNR – Should EMS Honor It?

In the March 2008 EMS Magazine there is an article by James J. Augustine, MD, FACEP. The title is Don’t Put That Tube In!

The article is about CPAP, which is an important topic and an excellent treatment that isn’t used anywhere near enough.

The patient is speaking and EMS is having trouble hearing her.The crew looks up at him. “Don’t put the tube in,” he reiterates. “She’s been on the machine before, and she doesn’t want that ever again. The tube means the machine, and neither of us will agree to that. Don’t put the tube in.”

That makes it fairly clear.[1]

Well, I may be a little slow, but to me that does not make the role of EMS fairly clear. I wish it did and I believe it should, but I’ve been in EMS too long to not see this as leading to a free for all of ethical, spiritual, legal, procedural, political, and administrative Monday morning quarterbacks sharpening their claws in preparation for a nice juicy sacrificial lamb, or two.

In the article the treatments help avoid intubation, but what if the patient progresses to respiratory failure?

How many EMS providers are permitted by state EMS law to observe such a patient’s spoken demand, even when accompanied by the backing of a family member?

If there is a DNR and the DNR is not the original prehospital DNR specifying no intubation, or if a family member disagrees with honoring the jumped through all of the hoops to be allowed to die outside of the hospital DNR, or any of the other possibilities that lead to this being far from clear.

Yes, the trained Protocol Monkey[2] will see that the best way to not get in trouble is to follow the protocols: I’m sorry, this is a standard DNR – not a prehospital DNR. I may not follow its clear documentation of your wishes, of your informed refusal of treatment. The state EMS laws absolve me of any responsibility for my actions when I violate a DNR.

Or PM may decide to call medical command to obtain orders to follow the valid legal document that was completed in good faith. If the patient is determined to need one of those treatments that the DNR refuses, the PM is obligated to provide the treatment while attempting to contact medical command, because What if medical command says to treat the patient against the patient’s wishes, for whatever reason?

Or PM laughs at the suggestion that a respiratory distress patient has the capacity to make informed decisions about care that the patient is very familiar with – much more so than the PM. The patient has got to be hypoxic to not want a prehospital non-RSI tube.

Or the responding EMS crew is a PM-free zone on that call and doesn’t automatically follow the state-approved Just Say No To DNR’s policy?

This is just assuming the policies of the state I am most familiar with. It may not be representative of other states. Maybe you live in a state that encourages its medics to use their own judgement, provides them with good initial training/continuing education to prepare for using that judgement, and aggressively follows up on cases where judgement is exercised.

So, given the many possibilities, how do you think you would act?

Use the case from the article or an example of your own.

I am interested in what people think about this, because I obviously do not see this conundrum as one that is set up to benefit the patient.

Why are we doing all of this, if not for the benefit of the patient?

Forcing a tube down the airway of a patient who does not want it, maybe to feel that we have given it our all, seems very wrong to me.

Footnotes:

[1] Don’t Put That Tube In!
EMS Magazine EMS World
March 2008
by James J. Augustine, MD, FACEP.
Article

[2] Protocol Monkey is borrowed from Ambulance Driver’s bestiary and has the uncanny ability to replicate itself faster than bacteria, is disposable, possesses a pulse, and has a medic card – what more could you possibly want in patient care?

Updated formatting and links 10-27-10 – 22:23
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Comments

  1. Well, I suspect you have opened up the box now! I agree that these situations contain a big ethical gray area when trying to comply with patients’ wishes and where it intersects the dreaded Protocol. Unfortunately, the back of a bus is not exactly the ideal setting to be wresting out solutions to such ethical quandaries. Hospitals assemble ethical committees that are brought in to help negotiate these situations when they arise in an in-patient setting. They have the benefit of time, colleagues, and input from medical-legal experts. No such assistance is afforded the EMS provider. It is unfair to ask the paramedic to make these type of calls. Enter, The Protocol.You know how I have personally felt about several of the more boneheaded protocols under which we both worked; but when it comes to medical-legal issues at least, I think they are designed to protect rather than hinder the provider.This is one reason why the much maligned Protocol Monkey has survived extinction, he has a very low frequency of bleating his way up onto an altar. This is not to say however, that you have to blindly Follow ze orderz! (my attempt at a German accent). We both know that The Protocol is more of a manufacturer’s suggested retail price than it is the inerrant, dogmatic, word of The Medical Director. That said, not every paramedic is equally as skilled at certain skills and occasionally there are intubations that simply cannot be performed. 😉

  2. I freely admit that as a counselor and not a paramedic, EMT, physician, RN, LPN or having any medical trainig beyond a CNA level (and even that is expired, as I am now a counselor), my knowledge in this area is a bit limited.I have one question and then a comment. Is there any barrier to having pre-hospital DNR forms on an ambulance and having sweet old ladies who are making an informed decision sign their own DHR at that time?Now on to my comment, which I guess may be a question as well. I thought that, as a patient, any form of treatment could be refused. If I am jogging and fall and sprain my ankle, I can sign a form and refuse treatment. Why can’t this be done for the little old lady? Is it an all or nothing? Refuse all treatment or accept whatever treatment is given pre-hospital? Please be gentle, as I am limited in my knowledge, but this subject is highly interesting.

  3. I think if you have a Living Will you should wear a medicalert bracelet to that effect and carry a copy folded neatly in your wallet. Not every care provider can possibly know that you have one and have a copy of it.And it needs to be specific. I’ve seen them ignored altogether because they were too vague. They need to outline in detail what one will and will not accept. DNRs are “iffy” in their span. Usualy those are signed in triplicate and relate to a single hospitalization unless they’re signed at a nursing home or other residential care facility. But then again, this is what Living Wills are for.To bamalaura, I’m speaking strictly from the inpatient point of view here but….patients can refuse treatment as long as they are conscious and can verbally confirm that they understand the risks vs. benefits of treatment but once their condition deteriorates, in the absence of a signed DNR or Living Will, we are legally obligated to do everything possible. Though as with inpatient DNRs (depending on the rules of your facility/state/governing body), one can potentially take a verbal refusal and document it on a form with two witnesses.Even then…good luck.

  4. I agree with previous commenters. If a patient is awake and able to indicate that he or she does not want it, it can even be considered assault and battery if it’s done.Just think of the damage if a patient IS intubated and doesn’t want to be, and can’t be removed from the vent. Ugh, what a mess.

  5. Vince, You approach it from the point of view of what is best for the provider, not what is best for the patient. While I do not think that what is best for the provider should be ignored, I think that we need to have the protocols more accurately reflect that the patient may be worth consulting in the patient’s care – especially when the patient has more experience being intubated than those usurping the patient’s ability to make an informed decision about her own care.Committee-wise (not that these words should be connected) remember that they often seek a compromise. If you are the patient this may not be one that works for you. Never forget the mission statement of committees – None of us is as dumb as all of us.

  6. Bamalaura,You bring up a lot of important questions, so I am answering them as a separate post, rather than as a very long comment. “What is a DNR and why do they cause so many problems?”

  7. In MD, at least, our patients can refuse whatever treatment they want, assuming they are alert and oriented. If a patient doesn’t want to be tubed, all they’ve gotta do is sign on the line and have a witness. If they can do that, no treatment for them. Of course, I can do my best to talk them out of it, and on the rare occasion that this does happen, I call a supervisor out to witness their refusal, but they can still refuse. I did have a patient once with a blood pressure of around 75/something too low to live for long, who was complaining of chest pain, weakness, and dizziness, but refused an IV or transport to the hospital. In the end, after calling the supervisor out and both of us doing my best to change her mind, she signed the refusal and it was back to the firehouse for some more sleep.