Guest Post – An Open Letter to Wisconsin Physicians Concerning Do-Not-Resucitate Orders

This is a guest post written by a local paramedic that has an important message to get out about Physician involvement with Do-Not-Resuscitate (DNR) Orders. Iíve included it in its entirety. Itís an important issue. It takes such an emotional toll on the EMS providers and the families of our patients. Please share this with your colleagues and loved ones.

———————————————————–

An open letter to the Physicians of Wisconsin:

ďMedic 1, Engine 7 respond to 123 Anystreet for a male unresponsive. Time out 21:19.Ē†

This simple statement spoken by a dispatcher starts a series of events that will place an EMS crew in a moral dilemma, a family in a confused and angry state, and a personal physician sitting at home, unaffected.† As the responding EMTs and Paramedics enter the home in response to this call, they see an elderly female cradling an elderly male in her arms. She is sobbing and distraught.† The elderly female holds in her hands the lifeless body of her life long partner and soul mate who seems to have finally given up his long suffering in this world.† The lead EMT quickly approaches the patient and finds that the patient is in cardiac arrest.† The female states that she always knew that he would die in her arms.† She states how long and difficult these last months have been with his terminal illness creeping into their lives and stealing her husband away.† The Lead EMT asks if the patient has a DNR (Do Not Resuscitate) order. The wife states that he does.† A quick check of wrists and ankles does not produce the state approved DNR bracelet.† The EMTís crew stares at Lead EMT looking for direction.† They know that unless there is a valid DNR bracelet on his wrist they must start CPR and perform life saving measures.† The Lead EMT knows that the clock is quickly winding down, they must act soon.† She asks the spouse again about the DNR and where it might be in the house.† The spouse states that there is a copy of the DNR at the hospital.† She states that she filled it out at the months ago at the doctorís office.† The spouse says, ďI never got a bracelet.† The doctor knows that he didnít want anything does, canít you call him?Ē

Meanwhile, a county away, a physician sits at his desk, dictating the notes of the day.† He is completely unaware of the drama that is unfolding in the darkness of night and the darkness that is enveloping one spouseís life.† This physician has practiced medicine for years, graduating medical school in the early 1960ís.† He has been kind, caring, and concerned for every patient he has seen and is highly regarded within the medical community.† When he first started in medicine, ambulances were simply Cadillac station wagons that whisked through the night.† They moved the sick and injured from point to point without offering much more than a fast ride.† Over the decades the rules changed, medical advances occurred, and now an ambulance is a rolling emergency department with full advanced life support abilities.† Unfortunately, unless a physician takes an interest in EMS this change has occurred without notice.

The lead EMT removes the patient from his spouseís arms.† They move him to the floor and start CPR.† The crew has no choice, they have no valid DNR order and they have been summoned by a 911 call from the spouse.† The spouse screams at and pleads with the crew to stop, she doesnít understand why this is happening.† Her husband has filled out papers; they have them on file at the hospital.† She thought this wouldnít happen.† The spouse watches as I.V.ís are started, defibrillator pads applied, and an endotracheal tube is placed into the airway of her spouse.† The spouse is now frantic.† This was never supposed to happen.† Why arenít the EMT listening to her? She knows what her husband wanted, they were together for over 50 years.† Medications are now being given and the EMS crew is trying to coax a pulse out of a tired heart.† The crew shoots looks at each other questioning what is right and wrong.

The lack of a DNR order puts EMS crews in a terrible moral and ethical dilemma.† They must proceed as the law states; but their hearts are heavy and they are unsure if they are truly doing the best for the patient or the family.† They sat in on the trainings years ago about the DNR bracelet.† The instructors said it would eliminate these situations, patients would speak to their personal physicians, sign all the necessary forms, and then the patient would be issued a DNR bracelet that would clearly state the patientís wishes.† Yet time and time again, this scenario repeats itself and each time the frustration grows.

After 45 minutes of CPR and three rounds of ACLS medication, medical control is contacted.† The ED physician is advised of the situation and advises the crew to terminate all efforts.† The crew cleans up and a mournful wife sits by her husbandís side again, holding his hand.† This is where she wanted to be all along, just holding his hand and looking for support in this darkest time in her life.† Instead, she had to witness the brutality of a full ACLS code.† The ribs breaking, the I.V.ís being placed, the monitor screaming out orders in its electronic voice.†† The peaceful, honorable death she had hoped for has been taken from her, she will now have the visions of CPR and strangers doing procedures to her husband that neither of them ever wanted.† These are events that we can never go back in time and change.

Our physician is now walking to his car.† Rattling through his pocket looking for keys that he canít seem to find.† He will receive a call later tonight from the county coroner explaining what has happened.† He will be honestly horrified to hear of the efforts by the EMS unit and will wonder why this has happened.† Ironically, he doesnít know that he set these events in motion years ago by not securing a DNR order for his patient that EMS crews are able to honor.

ďMedic 1 and Engine 7 are clear, no transport, coroner on scene.Ē† This will be another long ride back to the fire house.† Emotions are running high, the crew is upset.† They canít figure what is making them angrier, the fact that this happened or the fact they know it will happen again.† The cycle continues.

I would ask that each primary care physician look into the laws as they apply to DNR orders and EMS providers in the State of Wisconsin.† We do not have the luxury of time.† We must make decisions within seconds.† We NEED the DNR bracelet.† All we need to know is ďyes or noĒ to CPR.† We have NO time to read through long winded orders or other legal documents.† This is a problem that we must fix and fix fast. You have the power to fix this. Please do so.

Respectfully,

Todd A. Bluhm, Paramedic

  • emtbernice

    Holy moly… Todd was my EMT-B instructor. Seriously a small world here. :)

    It is so hard to have family members behind you begging you to stop and yet you have to continue on.

  • theroaddoctor

    I am assuming that you are not allowed to contact the ER at the outset, explain the situation, and ask for the DNR to honored even in it's absence at the scene?

  • medic1518

    theroaddoctor – We can always call med control, however the will likely default to working the code. The DNR bracelet that a patient recieves is viewed as the end all be all. Also, if we are going to code the patient time is of the essence, we really do not have time to be hunting down an ED physician.

    Thank you for your comment.

  • medic1518

    WOW!! Sorry for the typos, long day and late night. I got to get out of here!

  • medic1518

    emtbernice – when was I your instructor?? I wish I could remember all of my students but old age gets you sooner or later?

  • emtbernice

    In the spirit of keeping my identity as super secret as I can at this point (I'm sure some could figure it out… eek!) I'll just keep that one to myself. But you should know that you impressed me from day one, even when there was an real life emergency during the childbirth video. :)

  • medic1518

    theroaddoctor – We can always call med control, however the will likely default to working the code. The DNR bracelet that a patient recieves is viewed as the end all be all. Also, if we are going to code the patient time is of the essence, we really do not have time to be hunting down an ED physician.

    Thank you for your comment.

  • medic1518

    WOW!! Sorry for the typos, long day and late night. I got to get out of here!

  • medic1518

    emtbernice – when was I your instructor?? I wish I could remember all of my students but old age gets you sooner or later?

  • emtbernice

    In the spirit of keeping my identity as super secret as I can at this point (I'm sure some could figure it out… eek!) I'll just keep that one to myself. But you should know that you impressed me from day one, even when there was an real life emergency during the childbirth video. :)

  • medic1518

    Your identity is safe. I have no idea who you are!!

  • medic1518

    Your identity is safe. I have no idea who you are!!

  • http://www.nottrainedbutwetryhard.blogspot.com FireCap5

    I think all of us who are EMS practitioners have encountered this situation. We do not have the bracelet where I am, and it sounds like a good sound idea. But like everything else with DNR orders, it does no good if it is not there when we arrive. ACLS protocols are indeed brutal for someone who does not understand them to watch. We inflict mental trauma on loved ones in this type of situation. That pains me also. When my Father was dying of cancer, he expressed his wish for DNR. You better believe I made sure the orders were handy at all times. I did not want my mother to have to go through what I have seen others spouses go through. Thankfully, she didn't. My father was able to pass on in a dignified fashion.

    The failure is sometimes the patients families fault, but even then it is my opinion that the Doctor is the root cause of the mistake. This is not just writing a scrip. “Take two of these and call me in the morning” does not cut it with the DNR. More time and expanation of the process, including our role, needs to be made.

    Good post.

  • http://www.twitter.com/tbernemtp tbernemtp

    I have encountered similar situations in the past, terminally ill patient in cardiopulmonary arrest and no DNR present on scene, even though the family tells you that the patient has a valid DNR. In these situations, we usually contact online medical control and paint the picture and thankfully I've never been ordered to work the arrest or transport the patient. However, having that valid document on scene when needed virtually eliminates the need to take things to that extent.

    This continues to be a problem nationwide for EMS providers and I agree, it puts us in a major dilemma and makes our jobs more difficult than they should be. Your letter is very well written and paints a clear picture of the ongoing problem. I hope it raises some concerns in the right places and eventually leads to a fix for the problem. Good luck!

  • inthecity

    Unfortunately like practically everything else in EMS it'll probably take lawsuits to get actual changes made. DNR orders are great when they are actually present on scene or properly filled out or signed. Another thing to think about is family education for patients with DNRs. In the above situation was a multi-vehicle response really warranted? If the wife didnt want firemen and emts brutalizing her husband she should have thought about that before calling 911. Its a crappy situation that i think we've all been in and I hope that that letter dose not fall on deaf ears.

  • Tim

    The amazing thing is that state-by-state DNR rules differ so much. In North Carolina, DNR's were only permitted for terminally-ill patients and must be renewed every 30 days. It's was a basic form that was CPR/ No CPR.

    Here in Oregon, a DNR is a permanent part of your medical record and is printed on a fluorescent pink form. There is now even a state-wide registry that EMS providers can call 24/7 to verify. The POLST (Physician Orders for Life-Sustaining Treatment) is detailed and allows patients to decide what level of care they want, including information such as feeding tubes, antibiotics, etc.

    http://www.ohsu.edu/polst/programs/documents/PO

  • Tim

    The amazing thing is that state-by-state DNR rules differ so much. In North Carolina, DNR's were only permitted for terminally-ill patients and must be renewed every 30 days. It's was a basic form that was CPR/ No CPR.

    Here in Oregon, a DNR is a permanent part of your medical record and is printed on a fluorescent pink form. There is now even a state-wide registry that EMS providers can call 24/7 to verify. The POLST (Physician Orders for Life-Sustaining Treatment) is detailed and allows patients to decide what level of care they want, including information such as feeding tubes, antibiotics, etc.

    http://www.ohsu.edu/polst/programs/documents/PO

  • landfill624

    How about we as EMS providers push for some sort of “life-line” packet that can be hung on the fridge? Previous EMS services I have run with began utilizing an idea that would provide a list of medications, allergies, and special requests to the EMT's responding to the call, and there wasn't much debate about what was on it. Granted there are a couple of flaws with this idea:
    1) It may not stay updated enough to be effective
    2) Compliance is difficult to enforce, if they took it off the fridge for some reason and don't know where it is, then we are back at square one.

    I just figure this is something that the physicians can begin to use. If they are going to take the time to sign a DNR bracelet, why can't they sign a sealed packet of information with a magnet?

  • theroaddoctor

    That's what I was wondering. I love the idea of the bracelets. We don't have those here, and only have “paperwork” which can have several different forms. I advise people to nail these to the wall above their bed (no, not literally) to keep them nearby.

    I also highly recommend hospice services for those that qualify. EMS is never even contacted when someone dies that is under hospice care, nor is PD. It is a very dignified way to die, and much less traumatic for the family.

    I am lucky to work in a system that I don't have to track down an ED physician (this is due to a VERY proactive medical director), and will have my partner and first responders begin BLS measures until I can get the Doc on the line and explain the situation. I have never been denied stop resuscitation orders when requested. It's not the perfect answer, but it's what works for us.

    Thank for your letter however. Hopefully, some physicians will catch wind of it and take the time to understand what it means if they do not follow through on their end, as well as the need to explain to their pt's all that needs to be done on the patient's end as well.

  • http://www.twitter.com/tbernemtp tbernemtp

    I just wanted to add this into the thread, it's the new procedures we have going on here in North Carolina and sounds similar to the program Tim made mention of out in Oregon…

    http://www.ncdhhs.gov/dhsr/EMS/dnrmost.html

  • http://twitter.com/RogueMedic Jon Stevens

    G'day Lads,

    We don't have this program in Australia but I can definitely see the need for it! As a Military Medic I do a lot of placements with Road Ambulance, Air Ambulance and in Hospitals and we have to do full ACLS until a Doctor tells us to stop. I have been to several jobs where elderly patients have had their partners watch while these procedure are performed, even though they know their partner would've preferred not to have it done!

  • Tim

    Thank goodness for that. I'm glad NC has finally come around.

  • http://www.twitter.com/tbernemtp tbernemtp

    The unfortunate thing however, it doesn't seem like the MOST form is required with the DNR. The only time I've seen one is in training, yet I continue to encounter patients with valid goldenrod's. It's nice to have the MOST as an option, but it needs to be used…

  • http://piosocialmediatraining.com/ Greg Friese

    Tim, Thanks for the post. In a situation like you describe I would honor the spouses wish. Unfortunately she panicked and called 911 when she should have just called friends and family. The 911 call triggers a response.

    As others suggest I would also be calling medical control and if they urge your to begin resuscitation first have them talk to the spouse.

    The situations get muddier if you are at a CBRF or nursing home and you are told the patient has DNR orders but none are present. Then it becomes more difficult.

    A few final thoughts:
    1) discuss these difficult situations with your medical director and service director.
    2) revise your protocols to allow termination sooner than 45 minutes. 20 minutes seems to be common in other places.
    3) I don't think this is the fault of the patient's primary care physician. This is an issue to be resolved with your service, your medical director, and your online medical control.
    4) WI EMS Section DNR information http://dhs.wi.gov/ems/EMSsection/DNR.htm
    5) This is the start of a great series on termination of resuscitation http://paramedicine101.blogspot.com/2009/11/ter
    6) I think it would be better to defend that you did what the spouse asked you to do then defend your position against accusations of battery from the spouse.

    Anyway, great post. Thanks for sparking a good discussion.

  • http://www.twitter.com/tbernemtp tbernemtp

    The unfortunate thing however, it doesn't seem like the MOST form is required with the DNR. The only time I've seen one is in training, yet I continue to encounter patients with valid goldenrod's. It's nice to have the MOST as an option, but it needs to be used…

  • http://piosocialmediatraining.com/ Greg Friese

    Tim, Thanks for the post. In a situation like you describe I would honor the spouses wish. Unfortunately she panicked and called 911 when she should have just called friends and family. The 911 call triggers a response.

    As others suggest I would also be calling medical control and if they urge your to begin resuscitation first have them talk to the spouse.

    The situations get muddier if you are at a CBRF or nursing home and you are told the patient has DNR orders but none are present. Then it becomes more difficult.

    A few final thoughts:
    1) discuss these difficult situations with your medical director and service director.
    2) revise your protocols to allow termination sooner than 45 minutes. 20 minutes seems to be common in other places.
    3) I don't think this is the fault of the patient's primary care physician. This is an issue to be resolved with your service, your medical director, and your online medical control.
    4) WI EMS Section DNR information http://dhs.wi.gov/ems/EMSsection/DNR.htm
    5) This is the start of a great series on termination of resuscitation http://paramedicine101.blogspot.com/2009/11/ter
    6) I think it would be better to defend that you did what the spouse asked you to do then defend your position against accusations of battery from the spouse.

    Anyway, great post. Thanks for sparking a good discussion.

  • medic1518

    Greg,
    Thanks fo rthe response but I have to take issue with your third point. The DNR discussion should happen between the patient and their primary care physician. This topic is not to be handled by EMS or the medical control physician. I would be willing to go out on a limb and say that if you sat down 10 PMD's in this State, over half would not be able to tell you how the DNR effects EMS or if they would even acknowledge DNR's impact on how 911 EMS functions.

    Again, thank you for your input. It is by these communications taht we can all work toward a better system.

  • medic1518

    Greg,
    Thanks fo rthe response but I have to take issue with your third point. The DNR discussion should happen between the patient and their primary care physician. This topic is not to be handled by EMS or the medical control physician. I would be willing to go out on a limb and say that if you sat down 10 PMD's in this State, over half would not be able to tell you how the DNR effects EMS or if they would even acknowledge DNR's impact on how 911 EMS functions.

    Again, thank you for your input. It is by these communications taht we can all work toward a better system.

  • medic1518

    Greg,
    Thanks fo rthe response but I have to take issue with your third point. The DNR discussion should happen between the patient and their primary care physician. This topic is not to be handled by EMS or the medical control physician. I would be willing to go out on a limb and say that if you sat down 10 PMD's in this State, over half would not be able to tell you how the DNR effects EMS or if they would even acknowledge DNR's impact on how 911 EMS functions.

    Again, thank you for your input. It is by these communications taht we can all work toward a better system.

  • medic1518

    Greg,
    Thanks fo rthe response but I have to take issue with your third point. The DNR discussion should happen between the patient and their primary care physician. This topic is not to be handled by EMS or the medical control physician. I would be willing to go out on a limb and say that if you sat down 10 PMD's in this State, over half would not be able to tell you how the DNR effects EMS or if they would even acknowledge DNR's impact on how 911 EMS functions.

    Again, thank you for your input. It is by these communications taht we can all work toward a better system.

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background image Blogger Img

Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.
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  • Comments
    DiverMedic
    Welcome to the Club
    Very well done, Chris.
    2014-09-17 22:15:00
    DiverMedic
    My Blogroll
    One of these days you'll figure out where my blog is... :)
    2014-09-17 22:11:00
    emtterri123
    Six Tricks You Can Use Today to Improve Your EMS Narrative Report
    The first and best way to get people reading you to think that you are an idiot is to pepper your writing with spelling and grammatical errors. It makes you look dumb. - Me thinks this should have been restructured as it does not flow and caused me to reread it several times. lol :)
    2014-09-17 08:27:00
    –ź–Ľ–Ķ–ļ—Ā–Ķ–Ļ –†—É–ļ–ł–Ĺ
    So You Think You Can EKG?
    78% accuracy... and I'm not even a medical student, only a blog reader...
    2014-07-12 18:12:00
    Another One Bites the Dust (Part 2) | Medic15
    The Five Second Rule – Six Ways you can Reduce Pauses in Compressions and Save More Lives with CPR
    […] 5,7,9 http://www.lifeunderthelights.com/2014/03/24/the-five-second-rule-six-ways-you-can-reduce-pauses-in-… […]
    2014-07-09 18:39:31

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