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.
Todd A. Bluhm, Paramedic