HONORING LAST WISHES
You trained for hours, weeks, months to save lives. When those tones go off, you jump onto your rig and with the siren blaring, you race to the scene. When you arrive on scene, you rush in, carrying life saving equipment, and you are ready to work – but then you find that you are not allowed to.
A non-hospital DNR, Do Not Resuscitate, order means that you are not permitted to perform CPR if the person is not breathing and may be pulseless. There is the chance that the patient was having difficulty breathing or showed sign of other distress when the caretaker called 911, but by the time of your arrival… or even after you got there, his or her heart went silent. If there is a DNR present, then you are compelled to honor the patient’s (or the health proxy’s) wishes.
A MOLST form (Medical Orders for Life-Sustaining Treatment) can replace the DNR and DNI (do not intubate) directives, but can also include instructions on non-invasive respiratory support, pain management, and more. The MOLST can be used in a variety of settings as out-patient, facility or hospital. The MOLST is often completed with a physician or health care partner.
One EMT related the story of being called to the bedside of an elderly man, his room was filled with crying relatives begging the crew to help save his life. He was not breathing and already pulseless, they began CPR. Another relative came running in minutes later and demanded that they stop. After several minutes (while they continued compressions), he finally produced a signed DNR that was hidden at the bottom of a drawer. The crew was immediately instructed to stop CPR efforts, check for a pulse, and ONLY resume if there was a pulse. There wasn’t.
Ironically, if the man had been revived and especially if he had brain damage from lack of oxygen or even just broken bones from compressions, the patient/family would have had the right to sue the EMTs. The fact that the DNR was not produced, or even announced, in a timely manner, would probably have exonerated the responding crew. It is not uncommon that DNR or MOLST orders are not always presented to responders.
Even with a DNR or MOLST, if the patient was breathing but needed treatment for something like broken bones, pain, choking or other injuries, then treatment should commence. The forms do not forbid all treatment, they are meant to allow for quality of life and patient preferences. These forms represent the patient’s wishes for healthcare and must be honored by all medical professionals.
Responders should always assess the scene, do a rapid primary assessment of the patient, and always add on to the S.A.M.P.L.E. questions one more very important query, is there a DNR, DNI or MOLST form present. Check also for a DNR bracelet, if the patient is wearing one, assume that a valid DNR is in place. ALWAYS transport forms or bracelets with the patient. If contradicting paperwork is presented, then the crew needs to honor the wishes on the most recently dated form.
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