Introduction
Emergency medical services ( EMS) personnel (refers collectively to Emergency Medical Technicians - EMTs and First Responders) are required to provide emergency care and to transport patients to appropriate medical facilities. EMS personnel are further required to provide treatment to the fullest extent possible, subject to their level of training. However, more and more patients, where it is medically appropriate, are opting not to be resuscitated. Many patients arrange with their doctors for Do Not Resuscitate (DNR) orders; a doctor’s order directing that the individual not be resuscitated in the event of cardiac or respiratory arrest. However, since there is currently no uniform mechanism to enable EMS personnel to recognize DNR orders in out-of-hospital settings, EMS personnel have been obligated to perform full resuscitative measures when encountering a patient unable to convey directions regarding medical treatment.
While it is clear within the emergency medical services’ community that a patient has the authority to determine his/her medical treatment, EMS personnel have been unable to consider a patient's wishes regarding resuscitation in the out-of-hospital setting where the patient is either not conscious or not competent, due to the difficulty of ascertaining the validity of these wishes in the field under emergency conditions. Usually there is no ongoing relationship between the emergency medical services personnel and the patient. Emergency conditions require an immediate response and accurate identification. Authentication of individuals and documents is difficult, if not impossible, under emergency field conditions.
This Comfort Care / DNR (“CC/DNR”) Order Verification Protocol is designed to allow EMS personnel to honor a DNR order in an out-of-hospital setting. To date, there are no standardized documents by which EMS personnel can verify a DNR order in the field, under emergency conditions. This protocol provides for a state-wide, uniform DNR order verification, approved by the Department of Public Health (DPH), that EMS personnel can instantly recognize as an acceptable verification of an existing DNR order; thus, allowing EMS personnel to honor the patient's request for no resuscitation and to provide the patient with palliative care in conformance with the Comfort Care protocol.
Purpose
The purpose of this protocol is to: (1) provide a verification/authentication of DNR orders to enable EMS personnel to honor DNR orders in out-of-hospital settings; (2) clarify the role and responsibilities of EMS personnel at the scene and/or during transport of patients who have a current, valid CC/DNR Order Verification; (3) avoid resuscitation of patients who have a current, valid CC/DNR Order Verification; and (4) provide palliative/comfort care measures for patients with a current, valid CC/DNR Order Verification. This protocol is not intended to alter the physician’s standard of practice in issuing DNR orders in any way, but only to provide a standardized mechanism for the verification of the DNR order so that it may be recognized in out-of-hospital settings.
Definitions
For purposes of this protocol, the following are defined:
1. Attending Physician: A physician, licensed pursuant to M.G.L. c.112 §2, selected by or assigned to a patient, who is responsible for the treatment and care of the patient, in whatever setting medical diagnosis or treatment is rendered. Where more than one physician shares such responsibility, any such physician may act as the attending physician for purposes of this protocol.
2. Cardiopulmonary Resuscitation (“CPR”): Includes for purposes of this protocol, cardiac compression, artificial ventilation, oropharyngeal airway (OPA) insertion, advanced airway management such as endotracheal intubation, cardiac resuscitation drugs, defibrillation and related procedures.
3. Comfort Care / DNR Order Verification Bracelet (“bracelet”): A bracelet modeled after a hospital identification bracelet, which shall include the patient’s name; date of birth; gender; date of expiration, if any, of the underlying DNR order; and the signature and telephone number of an attending physician. The bracelet can only be issued to someone who has a valid CC/DNR Order Verification Form and must be issued by an attending physician. Wearing the bracelet is voluntary; however, it is strongly recommended for individuals who remain mobile.
4. Comfort Care / DNR Order Verification Form (“form”): A standardized state-wide form for verification of DNR orders in the out-of-hospital setting, approved by the Department of Public Health. The CC/DNR Order Verification Form shall include the patient’s name; date of birth; gender; address; date of issuance and date of expiration, if any, of the underlying DNR order; the signature and telephone number of an attending physician; and the signature of the patient, guardian or health care agent. The CC/DNR Order Verification Form is the only DNR document that EMS personnel will be instructed to honor and can only be issued by an attending physician.
5. Comfort Care / DNR Order Verification Protocol: A standardized state-wide patient care protocol to be followed by EMS personnel (EMTs and First Responders) when encountering a patient with a current, valid CC/DNR Order Verification Form and/or Bracelet. The protocol provides that the patient in respiratory or cardiac distress will receive palliative, comfort care consistent with the scope of the EMT’s training and certification, but no resuscitative measures. The protocol applies to all emergency medical services personnel (Basic, Intermediate and Paramedic EMTs and First Responders) operating in an out-of-hospital setting and requires that they perform patient assessment and treatment in accordance with this protocol.
6. Emergency Medical Services Personnel: Any EMT certified pursuant to 105 CMR 170.000 et seq. and any First Responder as defined in 105 CMR 171.050.
7. Guardian: An individual appointed by the court, pursuant to M.G.L. c. 201, §§ 6, 6A, or 6B, to make decisions for a person who is mentally ill, mentally retarded or unable to make or communicate informed decisions due to physical incapacity or illness, provided that the appointment as guardian includes the right to make health care decisions; or, a parent or other individual who is legally entitled to make decisions about the care and management of a child during his/her minority.
8. Health Care Agent: An individual authorized by a health care proxy to make health care decisions on behalf of the principal, pursuant to M.G.L. c. 201D. The authority of the health care agent becomes effective only upon a written determination of the attending physician, pursuant to M.G.L. c. 201D, § 6, that the principal lacks the capacity to make or to communicate health care decisions.
9. Life-sustaining procedure: Cardiopulmonary resuscitation, as defined in number 2 above. Life-sustaining procedures shall not include any medical procedure or intervention considered necessary by the attending physician, EMS personnel, or the medical control physicianto provide comfort care or to alleviate pain.
10. Medical Control Physician: A physician designated within the EMS system to provide on-line and off-line medical direction to EMS personnel.
11. Palliative care: Comfort care that eases or relieves symptoms without correcting the underlying cause or disease.
12. Out-of-hospital: Any setting outside a hospital where EMS personnel may be called and may encounter patients with CC/DNR Order Verifications including, but not limited to, long-term care, hospice, assisted living, private homes, schools, inter-facility transport, and other public areas.
AUTHORITY
It is well settled in Massachusetts that individuals, while competent, have the right to determine the course of their medical treatment, including the right to refuse medical treatment and to make end of life decisions. Norwood Hospital v. Munoz, 409 Mass. 116, 564 N.E.2d 1017 (1991); Brophy v. New England Sinai Hospital, 398 Mass. 417, 497 N.E.2d 626 (1986); Lane v. Candura, 6 Mass. App. Ct. 377, 376 N.E.2d 1232 (1978); and Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977). Similarly, it is recognized that incompetent individuals have the same right to determine the course of their medical treatment as well as to refuse medical treatment. Brophy v. New England Sinai Hospital, supra; Saikewicz, supra; Matter of Spring, 380 Mass. 629, 405 N.E.2d 115 (1980). See also, Matter of Dinnerstein, 6 Mass. App. Ct. 466, 380 N.E.2d 134 (1978); and Care and Protection of Beth, 412 Mass. 188, 587 N.E.2d 1377 (1992).
As an extension of the health profession into the field, the emergency medical system has the same obligation to recognize an individual's right to refuse medical treatment in an out-of-hospital setting, where the authenticity of the documentation can be validated.
Further authority: M.G.L. c. 111C and 105 CMR 170.000 et seq.; M.G.L. c. 111 § 201 and 105 CMR 171.000 et seq.
IMPLEMENTATION PROCEDURES
Eligibility : Anyone with a current valid DNR order is eligible for a CC/DNR Order Verification (Form and/or Bracelet), including minors.
A DNR order is an order, executed by a physician, issued according to the current standard of care. The standard for issuing the DNR order is neither defined nor changed by this protocol. This protocol simply serves to verify, for EMS personnel, a DNR Order issued by a physician.
Validity : To assure that a DNR order is recognized in any out-of-hospital setting, an attending physician must provide a patient, who has a current DNR order, with a fully executed CC/DNR Order Verification. Pursuant to this protocol, EMS personnel will be instructed to honor a current valid CC/DNR Order Verification Form or CC/DNR Order Verification Bracelet. Patients without CC/DNR Order Verification Form or Bracelet will be resuscitated by EMS personnel in accordance with standard EMS protocols.
Content : The CC/DNR Order Verification Form shall include:
The CC/DNR Order Verification Bracelet shall include:
Expiration : To the extent that the DNR order written by the physician has an expiration date, the CC/DNR Order Verification Form and CC/DNR Order Verification Bracelet, if issued, shall have an identical expiration date. This protocol does not prescribe an expiration date, but rather leaves the expiration date up to the physician. If the DNR order is revoked by the physician, patient, guardian or authorized health care agent, the CC/DNR Order Verification Form and CC/DNR Order Verification Bracelet, if any, shall be similarly revoked.
Access : This protocol is implemented solely through physicians. Only an attending physician can execute the CC/DNR Order Verification Form and provide the CC/DNR Order Verification Bracelet, if the bracelet is requested.
This protocol is activated when EMS personnel encounter a CC/DNR Order Verification Form or Bracelet. EMS personnel must:
If there is a CC/DNR Order Verification Form and/or a Bracelet, and either indicates a revocation or expiration of the CC/DNR Order Verification, EMS personnel shall resuscitate.
Patient Care : Upon confirmation of a current, valid CC/DNR Order Verification Form or Bracelet, EMS personnel shall follow the following procedures:
Established IV lines and advanced airways should remain in place.
Documentation : When a CC/DNR Order Verification Form and/or Bracelet is encountered by EMS personnel, it shall be documented. EMS personnel must also document palliative care provided to the patient and that the CC/DNR Order Verification Form or Bracelet is current and valid. Ambulance service personnel must document the presence of the CC/DNR Order Verification on the ambulance trip record.
Revocation : EMS personnel are not to honor any DNR request where the CC/DNR Order Verification Form or Bracelet, if present, is void or not intact. If there is a CC/DNR Order Verification Form and Bracelet, and either indicates a revocation, EMS personnel shall resuscitate.