'DNR'

[Sparky2004]

This was a hot topic when I was in Seneca. Do some people actually tatoo 'Do Not Resusitate' (if I spelled that right, lol) on their collar bone? Is this an 'urban legend', or is there actaual truth to this?

Thanks.

[bestcoast]

Never seen it or heard of it before.........BC....

[FFWannabe]

I sure hope it's an urban legend, although a weird one... I would hate to see poor old Bill, loved his wife Donna Norma Robertson so much he had her initials tattooed on his chest.....

Sue :)

[colin911]

Sounds like urban legend ... I too have never heard of it, and have never seen an actual DNR, most of the time we wouldn't get called for help in that situation. Of course if we were called, we must ignore the DNR and continue with our protocols.

And FFWannabe, that's pretty clever, that made me laugh.

[bestcoast]

I've been on calls where a DNR has been produced. Sometimes there is a miscommunication through 911 or it's suppose to be just a transfer but fire and ambulance show up emerg. If the DNR is current and everything is in order no attempts at resusitation (sp?) are made.......BC.......

[bcfire]

Ditto, bestcoast. Ne ver heard of it either!
BCFIRE

[ssifire]

Haven't heard of the tatoo, but I have seen the braclette's and the necklace on calls. Just a thing to remember on your RBS, although you'd already be doing CPR by the time you found them on a RBS if you're following protocols.

[911Caddy]

I've yet to come across a tattoo with "do not resuscitate"? But, I have heard of this topic. I'm sure it's an urban legend.. Legally it would be a bad thing to not start CPR should you come across a Pt. with this written across their chest or collar bone. The Pt's family could have afield day legally with you and your Dept for what may have only been someones idea of a BAD joke. Remember the DNR Form must have a current date with all the appropriate signatures. Not a Tattoo.. It's all about liability and covering your butt in the event of recourse from the Family.
SSIFire it sounds like you may have confused a Medical alert bracelet/necklace with a DNR which is an advanced directive form filled out by the Family physician and signed by the Pt.
When most pt's get close to the end of their terminal illness this form is completed.. Most people realize that advanced prehospital procedures/protocols would be futile as they are close to an ireversable medical condition. Most just want the suffering to end... When the end is very close for a Pt. reasoning can change as it is a very difficult time in ones life..
If there is any doubt on scene if CPR/AR should or should'nt be started for what ever reason.. start CPR/AR immediately. : )

[ssifire]

"SSIFire it sounds like you may have confused a Medical alert bracelet/necklace with a DNR which is an advanced directive form filled out by the Family physician and signed by the Pt." 911Caddy

Basically it is a mdeical alert bracelet stated there is a DNR in place. While legally you still need to see a sign DNR from a doctor. The bracelet lets you know the patients wishes, and to maybe have someone start looking for the DNR order. Let's face it, people don't always go in to cardiac arrest with a DNR taped to their heads.

[dentedhead]

I would not put the DNR tattoo in the "urban legend" catagory,more of a running joke in EMS. Usually After seeing another futile resus on a person who has quite frankly just died from TMB syndrome...to many birthdays.It is often accompanied with the phrase I can put my pet down, but cant end (insert relative here) suffering.

In order to honour the DNR a signed form must be present,in most cases these pts.are sent home to spend their remaining time in comfort and with loved ones.The resultant call to 911 comes when the family follows the DR.'s direction,when the pt.expires call me and I will come and take care of the certificates etc.Well most people generally dont wait to draw thier last during office hours so you call the GP get the answering service they hear someones died and tell the family to call 911.You/we are then met with no leave him/her alone "they are at peace now"or something to that effect.

It is a sticky situation but,you have to use common sense.I have been in situations like these where the pt has been washed, had fresh pajamas put on and all the nieghbourhood has been in for a visit.If you dont have standing orders you can always patch if this is available in your area.

Even more sticky is the elderly person who as they are pre arrest say "let me die Im ready" then what do you do?The law is the law so you have to work them.But how hard?

Sorry for the long post, but this is good yet complicated
topic.

Dentedhead

[BillyBlazes]

I just got back in the station from a medical call to a chinese nursing home for a 100 year old female diabetic. We were handed a "DNR" from 2001. Did not see a tatoo though.

[colin911]

Billy ... from 2001???? That girl sure had the will to live! It's our protocol that if we're handed a DNR, we have to ignore it and procede with CPR.

[bestcoast]

Billy ... from 2001???? That girl sure had the will to live! It's our protocol that if we're handed a DNR, we have to ignore it and procede with CPR.

Colin, you guys ignore a a DNR even if it is signed by a DR. and everything is current??....BC....

[Red_Devil]

Our policy is to carry one for the reason why we were called, if the homeowner doesnt give us access to patient then we would not continue, I say just let the medics figure it out...

[colin911]

Even if it the DNR is signed and current ... our position on this is that if someone called 911 for assistance, we are obligated to provide it. Unless there is a doctor present and can take responsibility for the patient, we have to carry on with our care. If the family does not let us in, we are to advised to call police and they will respond and arrest anyone interfering. There are instances of family members that disagree with the DNR and for example, the daughter calls 911, but the son doesn't want us to come. We show up and because 911 has been initiated, we have to provide care. (Even though, we might not want to)

[bestcoast]

That make's sense colin, sometimes we get the call after some screw up at 911. So we show up with ambulance and like i've said before it is suppose to just be a transfer or a non-emerg call and we have a DNR put in our face when we enter the door..........BC...

[bcfire]

So what's the deal guys? A current DNR is not valid? Do you automatically ignore a DNR because of a 911 call? We recognize a DNR when we respond if it is presented, if not,its all out. BCFIRE

[bestcoast]

So what's the deal guys? A current DNR is not valid? Do you automatically ignore a DNR because of a 911 call? We recognize a DNR when we respond if it is presented, if not,its all out. BCFIRE


In Vancouver a valid DNR is complied with, but ANY question about whether it's legit or not and full CPR, AED protocol is followed....BC.......

[bcfire]

Our policy is to carry one for the reason why we were called, if the homeowner doesnt give us access to patient then we would not continue, I say just let the medics figure it out...
Carry one what? A DNR? What are you talking about RD?
BCFIRE

[bcfire]

In Vancouver a valid DNR is complied with, but ANY question about whether it's legit or not and full CPR, AED protocol is followed....BC.......
Same here, very few DNRs out there. In a small community like ours DNRs are usually known to us. Tourist season is the wild card! Take care, BCFIRE

[dentedhead]

A DNR in Ontario is valid as long as it is current and signed by a Dr.It is terrible to have to be a PR to a distraught family member but, it is a legal document and will stand up in court.A valid DNR is a "contract" between a Dr. and a pt or power of attorney.In my experience you typically dont find people walking around with valid DNR's in their wallet.

A DNR should not be confused with a living will, directive of care or any other right to die organizations form such as the hemlock society.Unless it is two attached pages with the MOH insignia on the top and Do not resuscitate order clearly visible I might think twice.

As a FF I dont have the latitude I did as a paramedic,I can usually explain it to my Capt.without jeoperdizing anyones A#$. and the families wishes are met. If he is uncomfortable we carry on til EMS arrives albeit sometimes slowly.You gotta take your cue from the family as well.

Dentedhead

[dentedhead]

Billy,was that the Mon Chong? What you were given was probably a directive of care.For anyone in emergency services its not really something we can honour.It is for the recieving hospital to use to decide care based on pt.wishes.

If I remember correctly the only time we could honour it was on a transfer with a pt who was not expected to survive and a DNR had to be sent with it.

They can have a stale date,a DNR cannot.

Dentedhead

[FireEMTGuy]

If someone was to go to the extent of having a DNR tattooed on their body then they would most likely be aware of the strict rules and guidelines about DNR and the required information contained on and/or attached to it.

Simply having a DNR stuck to you in any way shape or form does not constitute a proper VALID DNAR.

Unless I see a proper, signed, dated, and valid DNR the pt. is to be worked, if viable.

[ssifire]

Even if it the DNR is signed and current ... our position on this is that if someone called 911 for assistance, we are obligated to provide it. Unless there is a doctor present and can take responsibility for the patient, we have to carry on with our care. If the family does not let us in, we are to advised to call police and they will respond and arrest anyone interfering. There are instances of family members that disagree with the DNR and for example, the daughter calls 911, but the son doesn't want us to come. We show up and because 911 has been initiated, we have to provide care. (Even though, we might not want to)

Better get use to seeing these patients without a doctor at the door. I live in a small community with a large elderly population. We are seeing more and more DNR orders at home. Generally, people with terminal illnesses are choosing to die at home, rather than sitting around in a hospital. The problem for us comes when the death process starts, while the doctors tell the families just to contact there offices, we in the emergency services have pounded 911 in to thier heads. When the emotional event of a loved one passing away takes place, peolpe forget numbers and call 911. Even if it's not for medical help.

If the DNR is signed and in order, I don't know how you can ignore it, even if your called to the scene.

As for the families getting in the way, if they're threatening me, the scene is not safe, and I'm out.

Colin911, why do you have to provide care because the daughter called 911? The DNR comes from the patient, or the patients LEGAL rep. It doesn't matter what the daughter wants. It's up to the patient to decide his or her wishes. If they have decided to sign a DNR, we need to respect that, where the daughter does or not.

That's the way I see it.

[colin911]

I'm just stating my department's position on a DNR order. I'm not a doctor or paramedic, so I wouldn't know what an authentic DNR looks like. Maybe if we had some training on it, that would help. I liken it to suicides ... if we get called to a suicide and unless the patient is Code 5 (obviously dead), we have a duty to provide care to that patient don't we? Even though he wanted to die, we still have to try to save him.

What if Mr. DNR wanted to live another day to see his grandchild's birthday. Or just simply didn't want to die that day for whatever reason.

Because 911 has been initiated, regardless of legal documents, we are obligated to help.

[Red_Devil]

SSfire, So your saying if you go into house and their is say an unconcious male on the floor, and you see a DNR but the daughter is saying do something, your direction is to comply with the DNR order and not do anything? That would be an extremely tough situation our protocol is to start cpr because we have been called there

[dentedhead]

Colin911,this might be a good thing for Capt Bradshaw to clarify for you guys if your SOG is a little older on this issue.DNRs and death at home are becoming more popular.

I certainly would not fault anyone for doing what you guys currently do.Thats one of the many things we are here for.

Dentedhead
P.S I worked with Dana many moons ago,I remember him as a pretty decent guy.

[Red_Devil]

I have spoken with Dana a few times, he is a guy who really knows his sh*t and is a really decent guy

[dentedhead]

SSfire, So your saying if you go into house and their is say an unconcious male on the floor, and you see a DNR but the daughter is saying do something, your direction is to comply with the DNR order and not do anything? That would be an extremely tough situation our protocol is to start cpr because we have been called there

No,the DNR is only valid for a VSA typically in an expected death,if the pt is breathing at all even if it is agonal, with any cardiac output they do not fall under a DNR.This where the directive of care I wrote about comes into play.

You are obligated to carry out Tx and transport on this type of pt.the directive of care or the DNR is then the receiving facilities guideline on how aggressive the Tx will be.

You may actually run into the opposite the pt is still"alive" 911 is unknowingly called by a third party you show up the family member says I have a DNR stop. Rule #1 applies.

Dentedhead

[colin911]

He's a great addition to the Training division. Our medical training has never been more organized or thorough. I don't think our SOG's for DNRs have changed, but I will confirm with him.

[dentedhead]

I have spoken with Dana a few times, he is a guy who really knows his sh*t and is a really decent guy

BINGO!
Dentedhead

[Red_Devil]

Ok now that makes sense, Fortunatly my experience with DNR's is i have seen one and like you said it was for the patient if they were VSA, she had agonal breathing...just barely breathing..we got there sametime as medics and they were presented with DNR, medic said ok stop we have a DNR here, I looked over at her chest which was barely rising and said shes still breathing..that point it was game on!

[BucketHead]

For someone to get a DNR order they actually have to go to their doctor and discuss the situation and sign a DNR form. The DNR is a legal document and if you initiate CPR, AR etc. you are going to quite simply get burned at the stake by a bunch of lawyers. The DNR is pretty much a one page form from the doctor that has the patients name, address, birthdate, signature and a few other misc, with DO NOT RESUSITATE right in bold letters on the top of the page, when you see the form you will know. If you end up in a situation when someone has a DNR you can provide O2, comfort the patient, and do a patient assesment. Once the patient gets to the hospital the doctors and nurses have a different set of rules to abide by. Anyways just got a call gotta go, hopefully this clears things up.

Cheers

[Rescue78]

I suggest you guys clarify all this with your Regional Base Hospital. In South Eastern Ontario, firefighters, and now paramedics are to honnor a verbal DNR from a relative. PERIOD.


A DNR order is not a Let Me Die Order. If there are vital signs, you are to inform the familly and do your best to maintain those vitals. Once VSA, then no efforts are made to regain vitals.
Is it unreasonable for the familly to call 911 even though there is a DNR in place? Absolutly not. How many people out there can assess vitals properly. That's why they call. They don't want to be the one who made the call. And quite frankly, if me leaving the hall to go check a set of vitals even though there is a DNR in place can make their grief any easier, then I'll gladly do it.

[dentedhead]

I suggest you guys clarify all this with your Regional Base Hospital. In South Eastern Ontario, firefighters, and now paramedics are to honnor a verbal DNR from a relative. PERIOD.


A DNR order is not a Let Me Die Order. If there are vital signs, you are to inform the familly and do your best to maintain those vitals. Once VSA, then no efforts are made to regain vitals.
Is it unreasonable for the familly to call 911 even though there is a DNR in place? Absolutly not. How many people out there can assess vitals properly. That's why they call. They don't want to be the one who made the call. And quite frankly, if me leaving the hall to go check a set of vitals even though there is a DNR in place can make their grief any easier, then I'll gladly do it.


Rscue78,I always find your posts both insightful and informative,however I disagree with the statement of honoring a verbal DNR "PERIOD".Is this for the end stage terminal pt?or the witnessed arrest?

I realize you state this is a base hospital directive.How specific is it?What constitutes a verbal.I cant think of too many DR.s who would put there license on the line for something as subjective as this.

I will use a call I did when I was still working EMS fultime.Its a call I havent forgotten because it was so odd.In an affluent area of TO were sent for an unconcious male,on arrival we found a male app.60 yrs lying on the floor he was VSA.The wife was understandibly distraught,yet still reasonably together,she asked us repeatidly to leave him be he had a "bad heart" and she went on to state how they had talked about this and he didnt want to be a vegetable.We proceeded with our protocols and on intubation found a bolus of meat about 3" in diameter.He choked and then arrested.

At the hospital I heard the Dr.speaking with her after he was pronounced and she basically said "good Im glad the bastards dead" Talking to the police later they told us that she was in fact glad he was dead apparently he wasnt the nicest husband in the world.Maybe he didnt want to be dead,she sure wanted him that way.The outcome in this call would have been the same regardless,but did that constitute a verbal DNR?


We seem to be on the same page on the other points. I think I have covered similar issues in previous posts.To honour a verbal there would have to be some pretty tight parameters.

Dentedhead

[Rescue78]

Dentedhead

Southeastern Ontario Region Base Hospital was the first in Ontario to make it's paramedics honnor a DNR. Up to two years ago, Fire Dept. would honnor the DNR but the paramedics came behind us and ignored it. Now, all emergency workers in the region have the same protocol.

In my opinion, once a relative tells you there is a DNR in place and you've confirm the VSA, the next question should be weather or not the familly know where to go from here. If an actual DNR is in place (not just a conversation that took place a year ago), there will be pre-arrangements in place. The doctor does not allow the DNR and say "Here you go. Go home and wait to die. I hope someone finds you before you stink." If the relative doesn't know what to do from here to dispose of the body etc., and the officer decides that there is ground not to honnor the DNR, then he'll make the call. If the relative becomes agitated and physical, then that becomes a safety issue and police should be made aware of the situation after your crew pulled back.

[dentedhead]

Rescue78 thanks for the clarification perhaps I misunderstood the use of the word verbal.I am still getting EMS out of my system LOL.

I think what your telling me is that this is something that has been agreed on by the pt,their family or power of attorney and physician and all parties are aware this is the wish of the pt.

This sounds like the directive of care that I posted about before,in your jurisdiction it must also double as the DNR.

Fair enough,thanks for clearing that up.

Dentedhead

[Rescue78]

Basicaly, what the policy means by verbal DNR by a relative is once the pt went through the proper chanels to get a proper, legal DNR, the relative can let emergency workers know, verbally, of the existence of such a document when they are called to the scene.


It is not meant as a pt that made a DNR verbally to their relatives so that they can pass it on.

I see where there could have been confusion.

[dentedhead]

Im with the program now.Thanks again its something that more base hospitals and the MOH should look at using province wide to cut down on the confusion.

This is also something more FDs should address as well.

Dentedhead

[Leafs Fan]

Rescue78, I work under the same base hospital as you do. What is your understanding if you are called to medical assist where one family member tells your there is a DNR and another family member is caught up in their grief and implores your crew to commence defib protocols?

I am under the impression that as soon as DNR is mentioned we simply check vitals to confirm vsa.

[Rescue78]

I would confirm VSA and insure that the relative that told me there is a DNR in place is in full understanding of what an actual DNR is. If so, honnor the DNR.

[Leafs Fan]

I would confirm VSA and insure that the relative that told me there is a DNR in place is in full understandinfg of what an actual DNR is. If so, honnor the DNR.

Thanks, that is what I thought to be the case.

[Roadwarrior]

I concur with Rescue78 and Leafs Fan. I am in the same area and that is the guideline we work under too.

[BucketHead]

In BC, we are required to have proof of a DNR otherwise we have to continue the call as if there wasn't a DNR in place. As for the verbal DNR it sounds a little strange to me. I can see someone getting themselves into a sticky situation when the elderly patient with severe dementia verbally insists on a DNR.

Just my thoughts,
Cheers

[Rescue78]

In BC, we are required to have proof of a DNR otherwise we have to continue the call as if there wasn't a DNR in place. As for the verbal DNR it sounds a little strange to me. I can see someone getting themselves into a sticky situation when the elderly patient with severe dementia verbally insists on a DNR.

Just my thoughts,
Cheers

Buckethead

You have obviously skipped a few posts while reading this thread. I clearly explained the meaning of a verbal DNR. Your example would not constitute one.

For your benefit, here is is again.

Basicaly, what the policy means by verbal DNR by a relative is once the pt went through the proper chanels to get a proper, legal DNR, the relative can let emergency workers know, verbally, of the existence of such a document when they are called to the scene.


It is not meant as a pt that made a DNR verbally to their relatives so that they can pass it on.

I see where there could have been confusion.

[mutts252]

I would confirm VSA and insure that the relative that told me there is a DNR in place is in full understanding of what an actual DNR is. If so, honnor the DNR.
same deal goes for us... if family members advise us of a DNR, we will not do anything once/if the patient is VSA. up until that point, however, we will do our best to maintain/improve the vitals that are present. if we are in the midst of CPR and are informed that a DNR is in place... we have to stop. in situations where family members may be divided on the issue (and there is a DNR in place)... hard thing to do, but we have to respect the patient's wishes and just stand back. :(

what really got my attention was when someone said that even if the DNR is presented to them, they will ignore it and continue with resus. attempts simplt because they were dispatched to the scene.... as far as i know, the DNR is a legally binding document/order, and i'm pretty sure you open yourself up to some serious legal issues if you were to 'save' the person and they didn't wish to be. major legal headaches might result from that one.... *especially* if you had been given the DNR and went on anyway (rather than just told about one).

[BucketHead]

My mistake