Case summary:

An ALS crew was dispatched to a a nursing home for an elderly woman who was unresponsive.  The found the patient in bed, unconscious, with irregular respirations and a GCS of 3.  Nursing staff advised the crew that the patient is on Eliquis and had fallen 4 hours ago and hit her head.  She had normal vitals after the fall and was acting normally until they found her in the present condition and activated EMS.  They also informed the crew that the patient was Do NOT Resuscitate Comfort Care (DNR-CC) due to having both ling and brain cancer.  The nursing facility staff contacted the patient’s daughter who requested the patient be transported for further care.  The crew requested the DNR form while they obtained vitals.

Vitals: BP 134/84,  HR 129,  RR 24,  Sat 45%,  glucose 230

They placed the patient on a non-rebreather and looked at the DNR form.  They noticed that the form was not completely filled out.  It had a noneligible signature and no printed physician name or date.  The crew contacted medical control and discussed their concern regarding how to proceed since they knew this patient needed an airway, however, they would not do this if they were following the DNR.  Med control recommended they respect the DNR as if it were filled out properly and provide supportive measures that were allowed by the DNR form.  The crew prepared the patient for transport and just prior to leaving, the nursing facility staff provided the crew another DNR CC form that was fully filled out and signed by a physician.  Patients oxygen saturation improved to the 90s but she remained unconscious for the entire transport to the ED.

Highlights of the case:

How to handle incomplete Do Not Resuscitate (DNR) forms

This patient almost certainly had a head blead from her fall that caused her presentation.  She likely was breathing very shallow which is why her respiratory rate was in the 20s but her O2 saturation was in the 40s.  In the absence of a DNR, this patient would need a C-collar, advanced airway and prompt transport to a trauma center.  However, an Ohio DNR-CC form would preclude advanced airways.  The crew correctly identified that a partially filled out DNR form does not provide the protections that a correctly filled out form does.  In these situations, we should render care as if the form did not exist, but we should also reach out to medical control to discuss.  The end goal is to provide care that is in line with the patient’s wishes, but this is hard for the unconscious patient since they cannot tell us what they want.  When in doubt, we always should render care since it is easier to de-escalate once we confirm things than the other way around.  Online medical control likely recommended following the initial DNR since it made medical sense for an elderly patient with both lung and brain cancer to be DNR-CC and likely the partially filled out form was an oversight, and that the patient likely did not want aggressive resuscitation.  EMS providers should not make this decision alone and should always involve medical control.  If the form is filled out completely and correctly, EMS should follow the instructions on the form.  This crew handled this situation perfectly and it turned out this decision was correct since the staff was able to later produce a complete DNR-CC form.

Treating the DNR patient

It is important to remember that DNR-CC means do not resuscitate and it does not mean do not treat.  This is true for hospice patients as well.  These patients have transitioned from focusing on life prolongation to instead focusing on symptom control and comfort.  This does not mean that they do not have EMS needs.  We might be called to treat symptoms that are not be adequately controlled by their current home or hospice regimen.  Our should be to try and control their symptoms to the best of our ability within the constraints of the patients advanced directives.  This might require transport to the ED for further symptom control if we cannot control them on scene.  It is also important to know that transport to the ED for symptom control does not revoke hospice.  Transport only risks revoking hospice if it is for the purpose of treatment for life prolongation.