End of Life Issues (DNR Information)

Paramedics and ambulance personnel called to a patient whose heart or breathing have stopped will always attempt resuscitation, with two exceptions. Resuscitation would not be attempted if it were not medically indicated—the patient was already dead and could not be helped. The other exception would be if the patient did not want resuscitation attempted.

If you would not want resuscitation measures taken in the event your heart stops or your breathing stops then you should plan ahead. Resuscitation measures include procedures such as cardiopulmonary resuscitation (CPR), electric shocks to the heart when indicated, assisted breathing, or medications to re-start the heart. Requests to refuse attempted resuscitation are known as Do-Not-Resuscitate or DNR requests. Paramedics and ambulance personnel will comply with several types of Do-Not-Resuscitate requests:

  • A family member tells the paramedics or EMTs that the patient does not want resuscitation attempted.
  • There is an Advance Health Care Directive completed with instructions not to attempt resuscitation.
  • A prehospital Do-Not-Resuscitate order has been completed and signed by the patient.
  • A substitute decision-maker with Power of Attorney for health care decides that you would not want resuscitation.

INFORMATION ON DO-NOT-RESUSCITATE (DNR) REQUESTS IN EMERGENCY MEDICAL SERVICES

This summary provides information about the types of Do-Not-Resuscitate (DNR) requests that will be honored in the field by paramedics and emergency medical technicians (EMTs) on fire engines and ambulances. Any documents about your preferences regarding medical care will also be helpful to physicians in the hospital.

The best resource for obtaining information is your own physician. Once you have read this summary sheet, you may want to write down any questions and discuss them with your physician. For general information, call Orange County Emergency Medical Services at 714-834-3500.

What is the success rate of resuscitation?
This is highly dependent on the reason the heart stopped and surrounding circumstances such as whether the patient’s collapse was witnessed, the type of heart activity, whether CPR was provided immediately and others. In general, patients having what we generally term as a heart attack with sudden collapse who were otherwise in good health may be resuscitated 20% of the time. A patient who is elderly with multiple medical problems will have a successful resuscitation much less often, perhaps between 0-3%. Both these estimates vary widely depending on the facts of an individual case.

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How likely is a patient to be left in a coma from which they do not awaken after CPR?
Most persons resuscitated successfully from cardiac arrest—who establish a pulse and breathing and are admitted to the hospital—wake up and survive. Adults who do not awaken within several days after having their heart restarted following a cardiac arrest usually die within a week. In many cases they die because supportive care is then withdrawn. Children who do not awaken are more likely to be left in a permanent coma.
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What does DNR mean?
DNR means, “Do Not Resuscitate”, or, do not attempt to restart a heart or breathing once they have stopped.

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What should I do if I do not want resuscitation attempted?
It is best if an individual completes a written form such as the prehospital DNR form or Advance Health Care Directive, but paramedics and EMTs will also honor family instructions. Family would typically be a spouse, adult child, sibling or other close relative aware of the patient’s desires. Another substitute decision-maker would be a person appointed as an agent for health care decisions under the Power of Attorney for health care
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What is a California Health Care Directive?
This is a legal document found in California law that allows individuals to appoint another person as agent to make health care decisions if the patient is unable to make their own decisions, or leave specific instructions for health care. It also contains portions for information about the donation of organs, primary physicians or other information.

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What is a living will?
“Living wills” may be a variety of documents and are generally not helpful in deciding whether a patient wants resuscitation. Living wills generally have wording as a “directive to physicians” to withhold care, if the patient has an incurable disease or illness certified to be a terminal condition by two physicians, where life sustaining procedures would only artificially prolong death and death will occur in a relatively short time. These conditions are not met if somebody has a cardiac arrest and paramedics are called. No one at that time knows whether or not the patient will respond and the certification by two physicians obviously cannot be performed. The living will or directive to physicians cannot be honored as a Do Not Resuscitate order in the field.
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How do I get a DNR order or other necessary paperwork?
It is important to speak to your doctor or home health nurse to assure your understanding of a DNR order. Your doctor or home health care nurse may have the paperwork you need. Prehospital DNR forms are available at: Orange County Emergency Medical Services or you may call 714-834-3500.

The Advance Health Care Directive and additional information are available from the California Medical Association or the California Coalition for Compassionate Care.

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What happens when paramedics or EMTs respond to a person with a DNR order?
      • If the person’s heart or breathing has stopped, there is a valid DNR order and the patient does not want treatment, paramedics and EMTs will not try to restart the heart or breathing.
      • The types of treatments that a patient with a DNR order would not receive include cardiopulmonary resuscitation (chest compressions and mouth-to-mouth breathing, or CPR), electric shocks to the heart, assisted breathing with mechanical devices, or the use of medications intended to start the heart again. (A person would not be placed on life support, such as a ventilator or a breathing machine).
      • A DNR order only applies when the heart or breathing has stopped. It does not affect care before the heart has stopped, for pain, shortness of breath or other symptoms.
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What will happen if I am in pain, or bleeding?
  • Patients with DNR orders receive full treatment for conditions like pain, shortness of breath, and bleeding. This is called comfort care.
  • The paramedic or EMT will always provide for patient comfort.
  • An airway obstruction or blockage in an awake patient will be treated. This is because an awake patient with airway obstruction would suffer severe distress
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What happens if I decide I no longer want to have a “DNR” order?
  • At any time, if you decide that you want to receive full treatment (e.g., CPR), the DNR order will be disregarded. If you change your mind when the fire department or ambulance arrive, simply tell the paramedics or EMTs that you do wish resuscitative efforts and that they should ignore the DNR order.
  • If you change your mind, it is important to tell your doctor and family your specific wishes, and request that all copies of your DNR order are destroyed. If you have a MedicAlert Do Not Resuscitate-EMS bracelet, you need to take it off and contact MedicAlert to update your records.

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What will happen if the paramedics come to my house, begin CPR, and my family members state that I am a DNR patient, but cannot find the written DNR order?
The paramedics will be able to discontinue unwanted resuscitative efforts. The only exception might be if there appears to be disagreement in the family.
It is important for your family or others to know the location of important documents, such as the DNR order. Some people place information about the existence of a DNR order on the outside of their refrigerator.

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What will happen if CPR is started and then my DNR order is found?
Once the DNR order has been identified, the paramedics may stop CPR and all procedures to artificially support life.

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Can a family member insist on resuscitation if the patient did not want resuscitation and completed a DNR?
The decision regarding resuscitation efforts belongs with the adult patient him or herself and to no one else unless the patient becomes incapacitated before making clear what their wishes would be. If a valid DNR order exists, that order and the patient’s wishes will be followed, unless there is substantial question about the accuracy or validity of the document. Patients have the right to make their own decisions.

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What if I live in a skilled nursing facility?
Paramedics or EMTs will comply with a DNR order written in your patient care record or chart. You should speak to the facility’s staff.

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What if I live in a residential care facility?
In general, residents in licensed residential care facilities will have 911 called even if they have a DNR request, since state law requires the facility to call 911. The only exception for the DNR would be if there is a licensed health care provider in the facility such as a registered nurse, and the patient is receiving hospice services. Although 911 would be called, if the resident has a prehospital Do-Not-Resuscitate form or instructions for no CPR in an Advance Health Care Directive, their desires would be followed if known.

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What Orange County Emergency Medical Services policy governs the use of Do-Not-Resuscitate orders in prehospital care?
Orange County Emergency Medical Services Policy/Procedures #330.51 governs DNR issues.

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