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.


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

[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