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

- Rogue Medic

Shock Me, Tube Me, Line Me

The emergency department (ED) is always noisy, but sudden screams from a staffer still get attention. The triage nurse is yelling, “…Not breathing, had vitals at triage, and just croaked,” as she runs toward us pushing a wheelchair. In it, a pale, thin woman is slumped over and looking gray. I’m the ED attending physician in charge. Amid the usual strokes, heart attacks, and bleeding ulcers, my day just became interesting.[1]

Amid the usual strokes, heart attacks, and bleeding ulcers, my day just became interesting.

This line just makes me want to cry.

First, I want to point out a bit about Dr. Veysman. He has written one of my favorite journal articles on pain management.[2] Here, he does demonstrate an appreciation for the possible pain the patient may experience throughout the resuscitation. However, resuscitation decisions are about more than pain.

Resuscitation – all of medical care – is about autonomy.

If the patient has the capacity to make informed decisions and is provided with appropriate information to make an informed decision, we need to respect that decision.

“Anyone know of a DNR on her?” I ask. If there’s a Do Not Resuscitate order, we won’t prevent her impending death, which means no chest compressions or electric shock for a dangerous heart rhythm. If there’s also a DNI (Do Not Intubate) order, we won’t insert a tube to help her breathe.

Blank stares all around. “Her daughter dropped her off with a chief complaint of weakness and went to park the car. I think she has cancer and is on chemo,” the triage nurse says. Without concrete proof of a DNR or DNI, there’s no hesitation. We resuscitate; we intubate. Click, klang, the laryngoscope snaps open and the patient has a tube down her throat within seconds. On the monitor, she is “flatlining”—no heartbeat—and she has no pulse.[1]

Concrete proof?

The decision to resuscitate should probably be prejudiced in favor of resuscitation, but have we gone too far in our attempts to do the impossible?

We are attempting to prevent death. We can only delay death. In some cases, we only prolong death.

We are also attempting to prevent being sued by someone for failure to treat a patient who could potentially be resuscitated. Is making the patients endure treatments they would refuse, if presented with accurate information for informed consent, acceptable if we do it to protect ourselves from liability?

Why is it considered ethical to subject patients to treatments just to protect us from the possibility that they might sue if there is a bad outcome? We do need to reform the way malpractice is handled, rather than force unwanted treatments on patients because of What if . . . ?

What if . . . ?

What if we treat patients with respect?

What if we present patients with the information they need to make informed decisions?

What if we allow patients to make those decisions, themselves?

We are there to help patients to live the lives they want to live. We are not there to impose our beliefs on them.

While I know that legally the lack of a DNR significantly ties our hands, I would expect most doctors to send someone running to find the daughter, who went to park her car.

I have worked in EMS in three states. Each state has made it clear. If I feel uncomfortable honoring a DNR, I am not required to respect the wishes of the patient. I can go above and beyond, but only in resuscitation, certainly not in pain management, or sedation. Ethical behavior in those cases would be very, very wrong.

I have known doctors willing to violate a DNR, but very few. I have known a lot more people in EMS who feel comfortable violating a DNR. Unfortunately, in Pennsylvania, the patient needs to have an original Prehospital DNR or we need to call medical command to get permission to honor a regular DNR or to honor any other kind of advance directive. There seem to be a lot of EMS people who will not make that call.

It appears that very few doctors in Pennsylvania are aware of this requirement for a Prehospital DNR, although it is stressed to EMS. If the patient does not have this bracelet or necklace or original document, we must start CPR.

The current approach is not the only possible approach, it is just the only one that people seem willing to discuss. Stefan Timmermans presents the other end of the spectrum. We do not need to go that far, but we are still too close to the other extreme. We do need to be more flexible in our approach to the inevitable.

If no relatives or friends are present, if I have no personal ties with the person dying, if I do not know the person’s wishes, and survival is not a near certainty, I would follow the advice I once heard a paramedic give a colleague: “If I were to collapse suddenly, close the door and check back in twenty-five minutes.” I would chose not to start CPR, and I would make the decision in good conscience. I would decline to subject a dead person to an invasive and traumatic intervention.[3]

We have patients who have valid DNRs, but they are not Prehospital DNRs. In Pennsylvania, the EMS law has rewritten the rules for patients who had every reason to expect that they were signing a valid document that would prevent unwanted attempts at resuscitation. Unfortunately, the patients have not read the fine print – fine print that is not on their DNR – invisible fine print clearly stating that they are using the wrong DNR for a patient outside of a hospital.

If I were diagnosed with a terminal condition and asked my doctor for a DNR, would my doctor know that there is only one acceptable form of DNR outside of a hospital in Pennsylvania?

If I were to visit someone in Pennsylvania from another state, would anyone realize that this would invalidate my out of state DNR, while I was in Pennsylvania?

If I obtain any other form of valid advance directive, will it been explained to me, that the EMS rules in Pennsylvania (and possibly most other states) make these valid legal documents essentially worthless outside of a hospital. Will I be told that I am wasting my time by jumping through hoops to document my wishes for treatment in advance of that need, when I still have the capacity to make those decisions?

Why does the person writing the EMS rules have the authority to tell those of us in EMS to ignore valid legal documents?

The answer from EMS management is that these documents are not valid, since they are not the document approved by the EMS department.

Why does the person writing the EMS rules get to decide what is a valid document?

Why is a written, witnessed, signed statement of an informed decision not valid only because it does not meet the standards of the people who oversee EMS?


We refuse to make difficult decisions, because we are afraid of the possibility that this patient, this time might be one of the few who might be capable of being resuscitated, if only briefly and painfully. A jury is expected to be unreasonable and to claim, They didn’t even try.

But what really happens when EMS is called?

With any advance directive that is not a Prehospital DNR, we are expected to start CPR before calling medical command for permission to honor the patient’s wishes. In other words, we are expected to force unwanted treatment on the patient because they do not have the right paper.

Someone calls 911 because the police have stopped using non-emergency numbers, as many police departments have done. Marauding vandals beheading your neighbors? Call 911. Barking dog? Call 911. Where can I get my car inspected? Call 911.

The family member is only calling to notify someone of a death, but it is an emotional time and they may feel they need to notify the police. 911 is the only number to reach the police. An ambulance is dispatched because there is a dead body. Never mind that this is a patient, who was receiving hospice care, and that there is nothing unexpected about this death. EMS arrives.

Maybe there is a DNR, but nobody can remember where it is. CPR must be begun, while the family looks for the paperwork. Thought you were stressed looking for your keys, when you were running late? Wimp.

Maybe there is a DNR, but it is only a copy, and EMS can only honor the original document. CPR must be begun. Maybe EMS calls medical command for permission to stop CPR. Maybe medical command grants permission.

Maybe there is a DNR, but it is not a Prehospital DNR. CPR must be begun, while the family blames themselves for this mistake. Perhaps EMS blames them as well, after all, that is what we have been taught during our DNR classes. It is the family’s fault. Maybe EMS calls medical command for permission to stop CPR. Maybe medical command grants permission.

Maybe there is an advance directive. CPR must be begun. Maybe EMS calls medical command for permission to stop CPR. Maybe medical command grants permission.

Maybe the patient is in a nursing home. The paperwork is not a Prehospital DNR. Since this is a patient in a nursing home, the paperwork is usually a note, scribbled in the margin, stating that the patient has a DNR. That kind of documentation is not even valid in the emergency department. Maybe there is a copy of the DNR paperwork. Maybe it is legible. Maybe EMS calls medical command for permission to stop CPR. Maybe medical command grants permission. Maybe the check is in the mail.

Most of the time, when I pick a patient up from a nursing home, when I ask about DNR status, they will tell me the DNR status, but they will not have the original paperwork. Sometimes there will be contradictory notes on the paperwork. On one page it states, Full Code, while on the next page it states, DNR.

It is as if we do not expect patients to have life threatening illnesses in nursing homes. Nursing home patients never go to the emergency department.

Then there is the problem of the escape clause. If an EMS provider does not feel ethically comfortable honoring the patient’s DNR, even if it is the Gold Standard Prehospital DNR personally signed by the state medical director, the medic’s medical director, and the medic’s mother, any EMS provider may decide that they just don’t want to respect the patient’s wishes. Dude, I haven’t had a tube in a while – Game on!

There is no provision for an EMS provider to acknowledge the obviously unethical rules and refuse to perform CPR on a patient with an advance directive, with the family all in agreement that their family member does not want CPR, and with a patient who has clearly wasted away over a period of weeks. A patient who would not have anything to look forward to, except having to die again if resuscitation produces a heart beat.

CPR was never intended to treat terminal illness.

I was called for a 51 year old patient with respiratory distress. He has a terminal respiratory condition. He has a DNR. He only needed treatment for an exacerbation of his underlying condition, so I did not have to deal with his DNR, but he did have a DNR. After the call, the two EMTs on the ambulance told me they would not honor the patient’s DNR, because he is too young. In EMS you can get away with that, because that is considered ethical to refuse to honor a DNR.

To sum up all of that, we need to change the rules, so that the rules serve the patients, not the other way around. We need to do this in a way that is ethical, and the current system definitely does not.

To me, resuscitating a cancer patient with a DNR puts me in the same league as those who provide medical care during torture. Keeping the person alive only so that they may experience the most pain possible. Dr. Veysman’s statement about his view of the same situation, “Amid the usual strokes, heart attacks, and bleeding ulcers, my day just became interesting.” That just breaks my heart.

I have had to call for medical command permission to stop CPR, not to withhold CPR, since we are supposed to be performing CPR while calling for permission. In the case of an advance directive, every time I have requested permission, medical command has agreed.

I cannot state that I withheld CPR while calling medical command, because that would be wrong. Of course I treated the family and the patient as if they are criminals having this forced on them for some valid reason. Of course I did. After all, that is what the state tells me is the only ethical thing to do.

Did I mention that, on one of these occasions, I waited for over eight minutes for the person who answered the phone to track down the medical command physician for permission to honor an advance directive?

Over eight minutes.

Only a medical command physician is supposed to answer the medical command phone.

Over eight minutes.

If I were giving epinephrine every 3 to 5 minutes and amiodarone in between, I would have maxed out on amiodarone before eight minutes. There is no maximum for epinephrine.

Over eight minutes.

Finally, the person on the other end of the line had to admit, I do not know where the medical command physician is. Maybe you could call another hospital.

Over eight minutes.

Then, I called another hospital. The medical command doctor picked up the phone. Permission granted to stop CPR. That is stop CPR, because I was certainly performing CPR the whole time, rather than attending to the needs of the family. To withhold CPR from someone who has clearly stated that it is not wanted would be very, very wrong.

I do not know what I would have done if I had been ordered to perform CPR, intubate, give drugs, et cetera. If I refused, would that prevent me from obtaining a job in a respectable line of work, such as prostitution? Fortunately, I have not had to find out. I am grateful every time I sit down.

Dr. Veysman does seem to have an interest in pain management and in avoiding suffering, but he seems to be suggesting that anyone with less of a love of their life, than what he thinks is appropriate, is making a mistake and needs to be preached to. I completely disagree with that approach.

If a person has made their own informed decision about what treatment they want, we should not be preaching at them to change their minds. I know too many people who will ignore the wishes of a patient with respiratory distress, after the patient makes it clear that intubation is not wanted, because the patient must be hypoxic and therefore the patient’s wish is not an informed decision. These same people will keep asking a patient with a DNR,Do you want us to save you? or Do you want us to help you breathe? Any positive indication at any point must be an informed decision by the patient to revoke their DNR, even though the patient is no less hypoxic than the patient who disagrees with them.

When guided by belief, too many of us only look for evidence that supports our belief.

Respecting the informed decisions of patients is an important part of medicine.

Back to the article.

“Unless the asystole is from too much potassium,” I reply. That would explain it. “Get two amps of bicarbonate. Take over compressions,” I say to the intern. “Central line kit, please.” The intern looks disappointed. He was hoping to do the line. I whisper, “Next time.” His training is important, but I’ll teach him more by saving the patient. Learning is slow, and slow is often OK—and sometimes better—because slow is careful. But this patient will die from slow. It’s a good lesson for him.[1]

But the first treatment for hyperkalemia ought to be the one that works fastest. Calcium.[4] Preferably calcium chloride, rather than calcium gluconate. Sodium bicarbonate only comes later. Perhaps the bicarb addressed something else.

Technicians attach the pads to the patient’s right shoulder and left ribs. “Guys, I know that’s the way the drawing’s shown on the pads,” I say, “but I want them on front and back. You’ll get better capture.” By this I mean that the electrical stimulus will be transferred more effectively and will better induce the heart to contract.[1]

On this, I completely agree. Anterior/posterior pad placement minimizes the amount of tissue the electricity needs to penetrate. This means that less energy is needed to obtain capture. This makes pacing more comfortable for the patient.

The pacer is working. Now there is a strong pulse, great blood pressure of 150/80, and her pupils are beginning to constrict, suggesting decent blood flow to the brain. I order a calcium infusion, another ampule of bicarb. The vitals stabilize. She maintains a normal rhythm without a pacer.

“Electricity works,” we like to say, and I’m grateful that the pacer did its job and is no longer necessary.[1]

A lot of things work, that does not mean that one causes the other. Was the electricity what worked this time? While the pacer can be a dramatic intervention, is there a reason to conclude that the patient improved because of the pacer? Maybe. Maybe not. We cannot tell from the article.

I introduce myself, and before I can go further, a man interrupts and hands me papers. “She has DNR and DNI orders,” he says.[1]

I carefully explain that everything happened fast. We weren’t aware of the DNR and the DNI.[1]

These are legitimate excuses, but they are only excuses. How hard did they try to find out if there was a DNR? When presented with a patient reported to have cancer, I am looking very aggressively for some way of determining what the patient wants done. Is there a DNR? Is there some other documentation of the patient’s wishes? What has the patient expressed to family members? What kind of cancer? What kind of prognosis? What treatments is the patient receiving? How has the patient been responding to the treatments? Et cetera.

For another perspective on the approach of Dr. Veysman, I decided to consult the writings of someone who might be able to tell me if the article reflects some hubris on the part of Dr. Veysman. Chess With God by Dr. Veysman.[5]

I suspect that Dr. Veysman is making a reference to The Seventh Seal,[6] where a man plays chess with death during the Black Plague. Yet, Dr. Veysman did not fool death. I would have used a different metaphor.

Without concrete proof of a DNR or DNI, there’s no hesitation.[1]

I think we need more hesitation, more discretion, and certainly more respect for patients.

Also covered in –

An ER Physician’s Take on DNR Orders
by Dr. Eric Widera

HEALTH CARE: This Is Why We Need Palliative Care
Author(s):Joanne Kenen
Published: March 3, 2010

For This Doctor, ‘DNR’ Means Do Not Resign
by Boris Veysman
morning edition


[1] ‘Shock me, tube me, line me’.
Veysman B.
Health Aff (Millwood). 2010 Feb;29(2):324-6. No abstract available.
PMID: 20348077 [PubMed – in process]

Free Full Text from Health Affairs         Free PDF from Health Affairs

[2] Truth hurts.
Veysman BD.
Acad Emerg Med. 2009 Apr;16(4):367-8. Epub 2009 Mar 6. No abstract available.
PMID: 19298618 [PubMed – indexed for MEDLINE]

[3] Sudden death and the myth of CPR
By Stefan Timmermans
Link at OpenLibrary.org

[4] The Wrong Juice
Movin’ Meat
by Shadowfax

[5] Chess with god.
Veysman BD.
Ann Emerg Med. 2010 Jan;55(1):123-4. No abstract available.
PMID: 20116017 [PubMed – indexed for MEDLINE]

Free Full Text from Annals of Emergency Medicine
Free PDF from Annals of Emergency Medicine

[6] The Seventh Seal
IMDB link