Prehospital do-not-resuscitate orders: a survey of state policies in the United States

National Guidelines for Statewide Implementation of EMS “Do Not Resuscitate” (DNR) Programs

With the growth of hospice and home health care, more patients with terminal illness are electing to avoid hospitalization until the final stages of illness. Many of these patients, as well as others with advanced chronic illnesses, have decided with the help and support of their attending physicians, that they do not wish to be resuscitated in the event of cardiac or respiratory arrest. However, as death draws near, well-meaning family or friends, or perhaps the patient, may call emergency medical services (EMS) personnel to transport the dying patient to the hospital; the prehospital providers who respond to these calls may be the last medical persons to attend terminally ill patients at home or in nursing homes. In many cases, these calls to EMS personnel are intended only to obtain transportation or comfort measures for the loved one. However, unless the state provides statutory authority for EMS personnel to honor a “do not resuscitate” (DNR) order, there may be a requirement for such personnel to attempt resuscitation, regardless of the patient's wishes and the physician's directive.

A qualitative study to identify barriers to local implementation of prehospital termination of resuscitation protocols

BACKGROUND

Despite the existence of national American Heart Association guidelines and 2 termination-of-resuscitation (TOR) rules for ceasing efforts in refractory out-of-hospital cardiac arrest, many emergency medical services agencies in the United States have adopted their own local protocols. Public policies and local perceptions may serve as barriers or facilitators to implementing national TOR guidelines at the local level.

METHODS AND RESULTS

Three focus groups, lasting 90 to 120 minutes, were conducted at the National Association of Emergency Medical Services Physicians meeting in January 2008. Snowball sampling was used to recruit participants. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified 3 distinct groups whose current policies or perceptions may impede efforts to adopt national TOR guidelines: payers who incentivize transport; legislators who create state mandates for transport and allow only narrow use of do-not-resuscitate orders; and communities where cultural norms are perceived to impede termination of resuscitation. Our participants suggested that national organizations, such as the American Heart Association and American College of Emergency Physicians, may serve as potential facilitators in addressing these barriers by taking the lead in asking payers to change reimbursement structures; encouraging legislators to revise laws to reflect the best available medical evidence; and educating the public that rapid transport to the hospital cannot substitute for optimal provision of prehospital care.

CONCLUSIONS

We have identified 3 influential groups who will need to work with national organizations to overcome current policies or prevailing perceptions that may impede implementing national TOR guidelines.

Identification of inpatient DNR status: a safety hazard begging for standardization

BACKGROUND

Ascertaining and documenting patients' preferences regarding end-of-life care is required by accrediting organizations at hospital admission. However, hospitals vary widely in their methods of making these preferences (including do-not-resuscitate [DNR] status) available to frontline providers, increasing the potential for errors.

METHODS

We surveyed 127 nursing executive members of the University HealthSystem Consortium (an alliance of academic medical centers), asking them to describe the current practices of their hospitals in identifying DNR orders. For those at institutions using color-coded wristbands, we also asked about other patient data depicted by wristbands and the choice of colors for DNR and these other indications. We used a commercial online survey tool with E-mail distribution.

RESULTS

Sixty-nine nurse executives completed the survey (54%). Fifty-six percent of hospitals use paper documentation as their only mode to identify DNR orders, 16% use electronic health records, and 25% augment either paper or electronic documentation with a color-coded patient wristband. Of those using color-coded wristbands (n = 17), 8 color schemes were reported. More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care.

CONCLUSIONS

Mechanisms to identify DNR orders vary significantly. For hospitals that use color-coded wristbands, the variety of color choices poses a risk for confusion and error. Building on existing and isolated state initiatives, a national mandate to standardize DNR identification and the color of patient wristbands would reduce the potential for errors and promote adherence to patients' wishes.

Implementation of a novel prehospital advance directive protocol in southeastern Ontario

INTRODUCTION

Do not resuscitate (DNR) orders are commonly accepted in most health care settings, but are less widely recognized in the prehospital setting. We describe the implementation of and satisfaction with a prehospital DNR protocol that allows paramedics to honour verbal and non-standard written DNR requests.

METHODS

This prospective observational study reviewed all cardiac arrests in southeastern Ontario between March 1, 2003 and September 31, 2005. Following a verbal or non-standard written DNR request, paramedics completed a questionnaire and a follow-up structured telephone interview was conducted with surrogate decision makers (SDMs).

RESULTS

There were 1890 cardiac arrests during the study period, of which 86 met our inclusion criteria. Paramedic surveys were available for 82 cases (95%), and surrogate decision makers (SDMs) were successfully contacted in 50 (58%) of them. Two SDMs declined to be interviewed. The mean patient age was 72.7 (standard deviation 13.8) years and 65% were male. Sixty-three (73%) of DNR requests were verbal, and 23 (27%) were written. The mean paramedic comfort was rated 4.9 on a 5-point Likert scale (with 5 being "very comfortable") (95% confidence interval [CI] 4.9-5.0). The mean SDM comfort was rated by paramedics as 4.9 (95% CI 4.8-4.9). SDMs reported comfort in withholding CPR in 47 of 48 cases (98%), and with paramedic care in all cases. One SDM stated that although it was consistent with the patient's wishes, she was uncomfortable having to make the DNR request.

CONCLUSIONS

Satisfaction with this novel prehospital DNR protocol was uniformly high among paramedic and SDM respondents. It appears that such a protocol is feasible and acceptable for the prehospital setting. Our conclusions are limited by a small sample size, the lack of a comparison group, and limited follow-up.

Moral moments at the end of life

Decision making near the end of life can be complex and laden with emotion for families and health care providers. Families and patients can prepare themselves for these difficult moments by thinking ahead about the patient's wishes and preparing clear documents that express those wishes. Health care providers can prepare themselves by being familiar with those documents, considering the goals of treatment, remembering the principles on which health care ethics are founded and knowing decision-making models that will help them to think through treatment plans and the best options for patient taking into consideration the goals of treatment.

Communicating advance directives from long-term care facilities to emergency departments

Many residents of long-term care (LTC) facilities are transferred to Emergency Departments without advance directives (AD). The goal of this study was to describe an ideal model for the transfer of AD from LTC facilities to Emergency Departments. Health care providers were asked to describe their ideal model for the completion and transfer of the ADs of LTC residents. A grounded theory methodology was used to identify significant themes. The model we present as a result of this analysis acknowledges the importance of simplifying and standardizing ADs, but focuses more attention on the process of completing and transferring the AD. A key feature of this model is an emphasis on the education of LTC residents and their relatives about ADs and advance-care planning. This education should involve a variety of resources used in creative ways; it should begin as soon as LTC placement is being considered, and the emphasis should be on providing information and discussing options rather than pressuring residents to make a decision.

Development of a statewide protocol for the prehospital identification of DNR patients in Connecticut including new DNR regulations

This article describes the development and implementation of a standardized protocol for the prehospital identification of terminally ill "do-not-resuscitate" (DNR) patients. This pilot program was initiated by members of the Connecticut College of Emergency Physicians and instituted on a voluntary basis statewide in July 1991. Key components of the program are discussed, including developmental rationale, formation of a DNR Coalition, educational rollout, and implementation activities. The second phase of this initiative involved passage of state legislation and development of new DNR regulations, which went into effect in July 1997. The regulations successfully addressed the limitations and difficulties encountered in the pilot program. Major modifications included applicability of the bracelet program to a broader group of DNR patients, development of a uniform system for interfacility transfer of DNR patients, and mandatory compliance by health care personnel.

Survey of state EMS-DNR laws and protocols

Author presents the results of a survey of state emergency medical services do-not-resuscitate laws and protocols that have been implemented statewide and describes their structural and operational characteristics, as well as responses from key state contacts on program challenges and issues.

Field experience with prehospital advance directives

STUDY OBJECTIVE

Some states have enacted legislation authorizing EMS providers to adhere to prehospital advance directives (ADs) in the terminally ill. This study was conducted to assess EMS providers' knowledge of and experience with prehospital ADs.

METHODS

An anonymous survey was conducted of 142 EMS providers employed by a local, private ambulance service in the northeastern United States. The survey was administered during a 2-month period from January to March 1995.

RESULTS

Of 142 participating providers, 106 (74.6%) completed questionnaires. Respondents included EMTs (61. 3%), paramedics (33.9%), and chair van operators (4.8%). The majority (58.6%) had at least 5 years of field experience. Almost all respondents (93.4%) were familiar with ADs, usually do-not-resuscitate orders. Most providers (78.3%) consider ADs before implementing extraordinary life support measures in terminally ill patients. Few (28.0%) have implemented prehospital ADs without medical control. The most commonly reported objections to withholding life support measures were fear of legal consequences, personal difficulty withholding care they are trained to provide, and ambiguity in the ADs received. Nearly all respondents (96.7%) support enactment of prehospital AD statutes.

CONCLUSION

Most prehospital care providers recognize the need to withhold resuscitative care in terminally ill patients who have prepared ADs. However, a sizable minority fail to consider prehospital ADs as a routine part of their practice. The majority of our respondents support enactment of prehospital AD statutes to minimize confusion and provide legal authorization to limit resuscitation.

Physicians' experiences with prehospital do-not-resuscitate orders in North Carolina

INTRODUCTION

Many states are implementing prehospital do-not-resuscitate (DNR) programs through legislation or by state or local protocol. There are no outcome studies in the literature regarding the utilization of, access to, or barriers to prehospital DNR programs, nor are there studies that evaluated whether they meet the patients' needs.

STUDY OBJECTIVE

To explore physicians' perceptions of the utilization of, access to, and barriers to a southeastern state's prehospital DNR program, and to identify key professional groups needing information about prehospital DNR issues.

METHODS

A convenience sample survey and a descriptive review using retrospective, self-report questionnaires sent to all physicians who requested and obtained a supply of the state's out-of-facility DNR forms in 1993.

RESULTS

Respondents reported that the most common terminal conditions for patients with prehospital DNR orders are cancer and multiple chronic diseases in elderly patients. More than half of the physicians recalled that enrolled patients had engaged the services of emergency medical services (EMS), most often because the patients' conditions worsened, and the families were uncertain about what to do. Most of the enrolled patients have at least one other DNR order in another health-care setting, and are at home with hospice care or home-health care at the time of the prehospital DNR order implementation. The most frequent barrier to honoring dying patients' wishes in the prehospital environment is a lack of knowledge of prehospital issues by patients, families, primary care physicians, and nursing home staff. Ninety-eight percent of the respondents support a single, universal DNR order that would apply across all health-care settings.

CONCLUSIONS

Patients, families, and key health-care professional groups need to be targeted with educational programs regarding prehospital DNR issues. Primary care physicians, using the current prehospital DNR program, support more comprehensive approaches to DNR orders across health-care settings.