Do Not Resuscitate Guidelines
Purpose: To establish guidelines for Three Star Fire Department First Responders to utilize when determining whether or not to resuscitate or provide medical assistance to the terminally ill patient.
Scope: A living will is a written document drawn up by a patient, a physician, and a lawyer. Similar documents are also drawn up, called advance directives, advance directives to physicians, durable power of attorney for health care, or do not resuscitation (DNR) orders. Living wills are often written when a patient has a terminal condition.
Resuscitation is a medical procedure which seeks to restore cardiac and/or respiratory function to individuals who have sustained a cardiac and/or respiratory arrest. "Do Not Resuscitate" ("DNR") is a medical order to provide no resuscitation to individuals for whom resuscitation is not warranted.
Cardiopulmonary resuscitation ("CPR") is the common term used to refer to resuscitation. However, the options available to treat very sick patients are broader than CPR as literally defined. Other options include intensive care, antibiotic therapy, hydration, and nutritional support. Appropriate comfort care measures should be employed for all patients, especially terminally ill patients.
Policy: DNR orders given to Three Star Fire Department shall invoke a protocol hereinafter referred to as the DNR Protocol. The DNR Protocol requires that emergency care and other health care providers:
NOTE: If DNR has been validated, Three Star Fire Department must honor all living wills, directives, and orders.
1. Perform routine patient assessment and resuscitation or intervention until valid DNR is confirmed.
2. Locate original DDNR order form.
a. Private Residential Settings (must be TN DNR form):
1) Patientís bedroom door
2) At the patientís bedside
3) On the refrigerator
4) In the patientís wallet
5) On the patient (EMS DNR bracelet or necklace)
Assure DNR order is valid and has not been revoked
6) Valid forms must be intact and not defaced.
a) Must see the original intact form (or approved alternate identification on the patient):
b) Tennessee DNR Form.
7) Revocation Ė The following people may revoke a DNR order:
a) The patient by destroying the DNR form or the EMS DNR order or by verbally withdrawing consent to the order.
b) The person authorized to consent on the patientís behalf.
c) A physician who is physically present at the patientís side.
3. Make a good faith effort to verify the patientís identity and assure patientís identity matches that on the DNR order form. Verification may be confirmed by photo identification or come from those present on the scene (i.e., patientís family, friends, or health care providers).
4. Patients in respiratory or cardiac arrest Ė withhold or withdraw the following treatments:
a. Artificial ventilation
d. Endotracheal intubation or Combitube utilization
e. Cardiac resuscitation medications
5. Appropriately treat patients who are not in cardiac arrest:
a. Airway open (no artificial ventilation, Combitube or endotracheal intubation)
d. Control of bleeding
e. Make patient comfortable (i.e., patient positioning) and be supportive
f. IV fluids and/or pain medication by protocol (ALS only)
g. Contact On-Line Medical Control if questions or concerns arise
h. Assure that the DNR order accompanies the patient if transported
6. If patient has expired:
a. Notify the police department through Central Dispatch Communications
b. Complete the patient care report form and note:
1) What type of DNR order was utilized (i.e., DNR form, DNR bracelet or necklace, direct order from physician or other DNR order)
2) DNR order number
3) Patientís attending physician
c. Comfort family members and be supportive
d. Preserve the scene and await arrival of law enforcement
7. Special considerations:
a. If the family becomes confrontational, insisting on resuscitation and demanding attempts regardless of a valid DNR order, begin CPR if needed and move the patient to the ambulance for transport. Contact Medical Control for further instructions.
b. In cases where no valid DNR order exists and CPR and resuscitation are indicated, resuscitate patient according to protocol. If the family becomes confrontational, demanding resuscitation be stopped, call for law enforcement. If the family interferes with resuscitation or threatens physical harm, stop the resuscitation. Seek a safe environment and await law enforcement.