Case summary:

An ALS crew responded to a 70s man who was reportedly having breathing problems.  They found the patient on the floor of the shower pulseless and apneic.  The wife told the crew that the patient’s code status was Do Not Resuscitate (DNR) but was not sure where the paperwork was.  The crew started manual CPR and managed the airway and ventilation with BLS techniques while the wife started looking for the paperwork.  The wife found the patient’s living will which specified his wife as the healthcare power of attorney (POA), but did not specify his code status.  His wife was adamant that he wanted his code status to be DNR and did not want him intubated.  While continuing compressions and ACLS care, the crew immediately contacted online medical control to get assistance on determining next steps.  The medical control physician spoke with the patient’s wife over the phone and helped her understand the care options.  After a short discussion, the wife decided that she would want all resuscitative measures taken.  The crew then placed an IO, intubated the patient, and then transported the patient to the hospital.  The patient remained in cardiac arrest the entire time.

Highlights of the case:

Try and determine code status as soon as possible.

When a patient is in cardiac arrest, we need to quickly determine if resuscitative efforts are something that they would want.  If the appropriate paperwork is at hand, great; however, this is rarely immediately available.  If there is any doubt or if the appropriate paperwork is not available, we should start resuscitative efforts.  This is because we can always stop CPR, but we cannot go back and start it up after the fact due to the anoxic brain injury associated with pauses in compressions.  This crew immediately inquired about code status and when the proper paperwork was not at hand, they started CPR.  This allowed them to continue resuscitation once the patient’s POA decided that she wanted resuscitative efforts performed.  If the crew had held compressions until this decision was made, it would have made any further resuscitation futile. 

The only DNR form EMS responders can follow without medical control is the Ohio DNR Comfort Care form (Ohio specific).

This section only applies to responders working in Ohio given that DNR laws are often state specific.  In Ohio, if a patient has a properly filled out Ohio DNR Comfort Care form, medical providers should follow the form and not attempt resuscitation.  This is even true if the legal POA is on scene and requesting resuscitation.  The key is that this form needs to be filled out properly and completely.  The key part that must be filled out is that the form must be signed both by the patient (or legal guardian) AND signed by a physician.  If an advanced practice provider (physician assistant or nurse practitioner) is the one signing, there is a separate line that must be signed by the supervising physician.  If the form is available and you confirm it has the proper signatures, then resuscitation should be stopped.  Remember that these laws vary by state, and it is important to follow the regulations in place in the state where you practice.  This crew was given a form that was not an Ohio DNR Comfort Care form, so they correctly continued resuscitation.  However, they also quickly involved medical control since their goal was to provide care in line with the patients wishes.

Our ultimate goal is to provide end of life care that is in line with the patient’s wishes.

While the only DNR form that we can follow in Ohio is the Ohio DNR Comfort Care form, our goal is to provide the care that the patient would have wanted if they were able to tell us their wishes.  Given that patients in cardiac arrest are unable to do this, the best point estimate of their wishes in the absence of a formal Ohio DNR is a different DNR and/or their family.  If the family or another form is requesting resuscitate, then we should resuscitate as we normally would.  If the family or another form is requesting we not resuscitate, then we should start CPR (since we do not have the Ohio form), but then immediately involve online medical control since a physician can help figure out the best course going forward.  Just because no formal Ohio DNR is available does not mandate us to provide resuscitation when all evidence points towards the patient not wanting this.  Our goal is to respect the patient’s wishes around end of life care and often the best estimate is what family is telling us.  While EMS in our system is not permitted to terminate resuscitation based on family wishes or a different DNR form on their own, if they get an online order from a physician, they are permitted to do so.  This crew realized that the wife’s request was the best estimate of what the patient would have wanted so they involved medical control in the decision making regarding on going care.