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Resuscitation And Refusals ECRN Review

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Title: Resuscitation And Refusals ECRN Review


1
Resuscitation And Refusals ECRN Review
  • Presence Regional EMS
  • Spring 2014

2
Objectives
  • Define the term advanced directives as it
    applies to EMS
  • Discuss the recognition and honoring of a Do Not
    Resuscitate order in the pre-hospital setting
  • List the criteria required for field termination
    of resuscitation
  • Discuss the assessments and documentation
    required for patients meeting Triple Zero
    criteria

3
  • Describe situations in which the criteria for
    Field Death Declaration is applicable
  • Review the criteria for refusal of treatment
    and/or transport
  • Describe situations that require contact with
    Medical Control

4
Right to Die Peacefully
  • All patients have the right to make decisions in
    advance about the circumstances of their death.
    More and more individuals are making these
    decisions. Health Care providers including EMS
    must be well aware of patient/family rights in
    these difficult situations.

5
Protocols and Policies
  • Refer to Region 6 Protocols for
  • Do Not Resuscitate Medical/Legal Policies Section
    C P. 7-9
  • Physician Orders for Life-Sustaining Treatment
    (POLST)
  • Termination of Resuscitation P. H09
  • Triple Zero P. H10
  • Field Death Declaration P. C14

6
Advanced Directives
  • Legal papers put in place before an emergency
    arises outlining individuals who are designated
    to make medical decisions for the patient, if the
    patient is no longer able to make decisions.
  • Durable Power of Attorney for Health Care
  • Surrogate Decision Maker
  • Living Will

7
Living Will
  • A witnessed written documents voluntarily
    executed by a person with the proper formalities
    instructing the persons physician to withhold or
    withdraw death delaying procedures in the event
    that the person is diagnosed as having a terminal
    event.

8
  • EMS providers will not be held responsible for
    determining the validity of a Durable Power of
    Attorney, Surrogate Decision Maker or Living
    Will.
  • A Durable Power of Attorney, Surrogate Decision
    Maker or Living Will alone cannot be accepted as
    the means to halt resuscitation by EMS providers

9
  • If a patient is found in cardiopulmonary arrest
    and EMS providers are presented with a Durable
    Power of Attorney, Surrogate Decision Maker or
    Living Will, CPR must be started and Medical
    Control contacted immediately for direction.

10
Whose orders does EMS follow?
  • EMS providers follow the orders of a physician,
    not legal paperwork.
  • Medical Control may
  • determine that the
  • legal paperwork is
  • sufficient to halt
  • resuscitative measures

11
Do Not Resuscitate
  • Do not resuscitate orders ( DNR) orders are
    physician orders which advise nursing and EMS
    providers that if a patient suffers a
    cardiopulmonary arrest, the patient does not wish
    to be resuscitated.

12
DNR
  • Because a DNR is an order from a physician, a
    valid DNR can be honored by EMS providers.

13
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14
2013 IDPH Form
  • To find a copy of the form go to
  • www.idph.state.il.us
  • Click on A to Z
  • Look up Do Not Resuscitate form

15
2013 IDPH Form Basics
  • Uniform Do-Not Resuscitate Advance Directive
  • Part A Attempt Resuscitation/CPR
  • Yes/No
  • Includes intubation and mechanical ventilation

16
  • Physician Orders for Life Sustaining Treatment
    Part B If a patient has a pulse and/or is
    breathing
  • Comfort measures only
  • Limited additional interventions
  • Intubation and mechanical interventions

17
  • Part C Artificially administered nutrition
  • Feeding tube yes/no
  • Part D Documentation of discussion
  • Signatures of patient, family and witness
  • Part E Signature of attending physician

18
A Valid DNR
  • A DNR is valid if it is on the appropriate IDPH
    form
  • It must be signed by the patients physician
  • It must be signed by the patient or their durable
    power of attorney/surrogate decision maker.

19
Please note
  • THE DNR DOES NOT HAVE TO BE RESIGNED WITHIN A
    PARTICULAR AMOUNT OF TIME IN ORDER TO REMAIN
    VALID
  • THE DNR DOES NOT HAVE TO BE ON ANY PARTICULART
    COLOR OF PAPER

20
Revoking a DNR
  • A DNR may be revoked if
  • It is physically destroyed or rescinded by the
    physician who wrote the order.
  • It is physically destroyed or rescinded by the
    person who gave consent to the written order

21
When presented with a DNR
  • EMS makes a reasonable attempt to verify the
    identity of the patient named in the DNR.
  • If the validity of the DNR is unclear EMS begins
    CPR and call Medical Control

22
IF the patient is in cardiopulmonary arrest and
  • No valid DNR order is produced
  • No agreement by the family on the DNR
  • Family is very upset
  • EMS providers complete an assessment of the
    patient begin CPR and call Medical Control.

23
  • Medical Control (ED Physician with ECRN)
    determine if the patient is resuscitated or not.

24
DNR does not mean Do Not Care
  • Resuscitation is
  • CPR
  • Electrical defibrillation
  • Tracheal intubation
  • Manually assisted ventilation
  • Part A
  • Resuscitation is not
  • IV fluids
  • Dextrose IV These are Physician Orders
  • Suctioning for life-sustaining treatment
  • Oxygen administration
  • Part B and Part C

25
Whenever a patient with a DNR
  • Suffers cardiopulmonary arrest, EMS calls Medical
    Control for direction if
  • The patient is being transported to and from home
  • The patient is at a long term care facility
  • The patient is on an inter-hospital transfer
  • The patient is a Hospice
  • EMT needs clarification and confirmation of
    actions

26
All Patients with Valid DNR Paperwork
  • Call Medical Control to document incident on a
    recorded line.

27
Whenever a patient with a DNR
  • Is not in cardiac arrest
  • Treatment is started according to applicable
    protocol

28
Termination of Resuscitation
  • Resuscitation may be halted without a Do Not
    Resuscitate order if
  • Patient is found in asystole
  • Unwitnessed arrest with no bystander CPR before
    arrival of EMS
  • Patient remains in asystole despite the treatment
    of the Asystole protocol
  • CPR
  • Airway secured
  • Vascular access
  • Epinephrine 1 mg

29
Termination of Resuscitation
  • In order to Terminate Resuscitative efforts for
    the previous criteria
  • EMS must call Medical Control for permission to
    terminate resuscitation and put incident on the
    recorded line
  • The family must be in agreement with the
    termination
  • EMS must call the local coroner

30
Before the wheels roll. . .
  • The decision to terminate resuscitation must be
    made before the wheels of the ambulance roll to
    transport a patient to the hospital.
  • No way to register a dead person.

31
Triple Zero
  • A patient who is not viable and for whom
    resuscitation efforts would be fruitless
  • Unconscious
  • No pulse
  • No respiration

32
Triple Zero Signs of Long Term Death
  • The patient must exhibit one or more of the
    following signs
  • Rigor mortis stiffness of the limbs
  • Lividity pooling of blood in dependent parts of
    the body
  • Decomposition
  • Mummification
  • Decapitation
  • No resuscitative efforts for at least 20 minutes
  • No palpable pulses.
  • Asystole in 3 chest leads (Lead I, II, III)

33
  • Contact Medical Control
  • Document findings
  • Time Triple Zero confirmed
  • Physician on the radio
  • On recorded line
  • The confirmation of Triple
  • Zero does not constitute
  • a pronouncement of death.

34
Remember
  • EMS must call the local coroner
  • EMS must stay with the patient until relieved by
    coroner or local law enforcement

35
If any doubt exists,
  • Whether patient meets criteria for Triple Zero
  • RESUSCITATE
  • Especially if
  • suspected hypothermia
  • drowning/near drowning
  • uncertain down time

36
EXCEPTION
  • ALL INFANTS WHO ARE VICTIMS OF SIDS ARE BROUGHT
    IN TO THE ED WITH RESUSCITATION ATTEMPTS!!!

37
Field Death Declaration
  • Chance of survival from traumatic cardiac arrest
    at the scene is minimal
  • Must make the best use of time, personnel and
    resources
  • Protocol approved for all levels of EMS providers
    (FR-D, Basic, Intermediate, Paramedic)

38
Criteria for Field Death Declaration
  • gt 14 years old
  • Significant mechanism of injury
  • Pulseless and not breathing on EMS arrival
  • No active electrical activity on the monitor
  • or No Shock Indicated on AED
  • Asystole or Idioventricular Rhythm
  • MAY BE WARM WITHOUT RIGOR OR LIVIDITY

39
So what if?
  • EMS is called to the scene of a 27 year-old male
    in a motor vehicle crash. The vehicle was
    traveling at a high rate of speed and rolled over
    sustaining heavy damage. The patient was ejected
    and is found face down 20 feet from the vehicle.
    On initial assessment EMS finds the patient
    pulseless and apneic.

40
How should EMS to proceed?
41
Patient
  • Is an adult ( over the age of 14)
  • Trauma resulted in significant mechanism of
    injury
  • Patient was pulseless and not breathing on
    initial assessment
  • Major trauma to the body found on assessment

42
  • On the monitor the patient does not have a
    viable rhythm

43
Important Point
  • Medical Control MUST BE CONTACTED on a recorded
    line for all Field Death Declaration
    questions/decisions

44
Remember
  • EMS must call the local coroner
  • EMS must stay with the patient until relieved by
    coroner or local law enforcement

45
Review of Refusal Criteria
  • Refusal of treatment/transport should be
    initiated by the patient.
  • At NO time should any EMS provider suggest or
    initiate a patient refusal.
  • Upon refusal of treatment and/or transport, the
    EMS provider should evaluate the patient.

46
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47
Evaluation - Mental Status
  • Is the patient alert and oriented to person,
    place, time and event?
  • Is the patient free of the influence of drugs or
    alcohol?

48
Evaluation - Vital Signs
  • Evaluate airway, breathing and circulation.
  • A complete set of vital signs should be obtained.
  • If patient refuses to have vital signs taken, the
    EMS provider should use a visual and verbal
    assessment to determine if vital signs are
    altered.

49
Evaluation - MOI / NOI
  • Is the scene free of significant mechanism of
    injury?
  • Does the patient have a life-threatening chief
    complaint or evidence of significant signs and/or
    symptoms?
  • Is the patient free of pertinent medical
    history?

50
Evaluation - Competence
  • Is the patient 18 years of age?
  • If the patient is not the appropriate age
  • Does the patient proof of emancipation?
  • Is accompanied by parent or legal guardian?

51
Review of Refusal Criteria
  • EMS must explain possible risks and complications
    that may occur if treatment and/or transport are
    not provided.
  • This may include death or reduction in quality
    of life if the patients condition is considered
    life threatening by the EMS provider or Medical
    Control.

52
Refusal Form Documentation
  • EMS providers complete the PREMSS Refusal form by
    answering all questions in the upper portion of
    the form.
  • Document scene and assessment findings in the
    space labeled Notes/Comments.
  • Document vital signs in the space provided.

53
Medical Control
  • Medical Control must be contacted when
  • Any question in the upper portion of the refusal
    form has been answered NO
  • If a patient refuses transport after EMS
    treatment has been initiated
  • All AMA refusals
  • When Medical Control is contacted, check the box
    next to the hospital contacted and print the
    physicians name on the line indicated

54
Medical Control
  • By calling Medical Control, EMS is not looking
    for approval of the refusal.
  • Medical Control is confirming the efforts of EMS
    in assuring that the patient is safe and
    competent to refuse treatment.
  • EMS is documenting the questionable refusal on a
    recorded radio/phone line for legal purposes.

55
Summary
  • Know the policies and protocols regarding end of
    life/ resuscitation decisions and refusal of
    care.
  • EMS must always notify Medical Control for
    documentation on a recorded line and guidance.
  • EMS must call the coroner in the cases of death
    outside the hospital.

56
Review
  • Consider the following 12 Scenarios
  • Answer all the questions for each scenario .
  • Please e-mail your answers to
  • Mary.butzow_at_presencehealth.org
  • ECRN CE in subject box.
  • You will receive an e-mail confirmation with the
    correct answers. Print this confirmation for
    your records.

57
Scenario 1
  • EMS Providers are called to a motor vehicle
    crash. The driver of one car is pulseless and
    not breathing. He has massive damage to both
    lower extremities and a mushy area on his scalp.
    He is in asystole on the monitor. Does this
    patient meet Field Death Declaration criteria?
    What should EMS do?

58
Scenario 2
  • EMTs have been called to the house by neighbors
    concerned that they have not seen Floyd all day.
    Floyd usually takes his dog out for walks at
    least twice a day, but no one has seen him since
    yesterday. Police find Floyd in his recliner,
    pulseless and not breathing. He has purple
    discoloration of his dependent parts and is very
    stiff. The monitor shows asystole in all leads.
    Does Floyd meet Triple Zero criteria? What should
    EMS do?

59
Scenario 3
  • Mary Janes mother has cardiac arrested. Mary
    Jane thinks her mom has a living will, but she
    cant find it. She has never heard of a durable
    power of attorney. What should you advise EMS to
    do?

60
Scenario 4
  • Susan is lying in her back yard. It is early
    April, railing and about 50 degrees out. She is
    not moving, stiff and cold to touch. EMS cannot
    find any pulses on her and she does not appear to
    be breathing. Does she meet criteria for Triple
    Zero? Why or why not?

61
Scenario 5
  • Mr. Blue has a signed Do Not Resuscitate order
    for his mother who is 90 years old with cancer.
    Now that she is pulseless and not breathing he
    has changed his mind and wants everything done.
    What should you advise EMS Providers to do?

62
Scenario 6
  • Mrs. Green is dying of cancer. She has a DNR.
    Mrs. Green has suffered a cardiac arrest and the
    local fire department has started CPR. The
    paramedic with the transport agency has called
    for guidance as to what to do now. What do you
    want to advise him to do?

63
Scenario 7
  • Mrs. Schmidt has suffered a cardiac arrest.
    Responding EMS Providers have started CPR. She
    is entubated, given epinephrine and remains in
    asystole. CPR continues, she is given additional
    epinephrine. The family is crying please let her
    go. What should you advise EMS do? What
    protocol does this follow?

64
Scenario 8
  • It is snowing and the EMS transport unit can only
    go about 20 miles an hour on the highway. On
    board they have a 6- year-old boy who was hit by
    a car in a rural community. The child is
    critical and had a pulse at the scene but about
    10 minutes ago he went into cardiac arrest. EMS
    has done CPR, intubated him, and started IV
    fluids. They have given Epinephrine according to
    protocol. He is asystole and EMS is still 8
    miles from the hospital.

65
  • Does this child meet Field Death Declaration?
    Why or Why not?
  • Does this child meet the Termination of
    Resuscitation Protocol? Why or Why not?

66
Scenario 9
  • Erics mom is in the Hospice program for
    emphysema. She has a valid DNR signed by her, her
    doctor and Eric. Erics mom is in cardiac
    arrest. Eric wants to honor the DNR but his
    sister just got here from Florida and she is
    screaming save my mother!!. What should you
    advise EMS to do?

67
Scenario 10
  • EMS is dispatched for a 32 year old male patient
    with a diabetic problem. Upon arrival they find
    Tony lying in bed. He is unresponsive but
    breathing. His skin is pale, cool and clammy.
    His blood sugar is 40 mg/dl.
  • Providers obtain vascular access and administer
  • 25g of 50 dextrose

68
  • After administration of the dextrose, Tony wakes
  • up. He is a little slow to respond but is alert
    and
  • oriented x4. He wants to refuse transport to the
  • hospital.
  • Can Tony refuse transport?
  • The EMS providers call Medical Control, how will
    advise them to proceed?

69
Scenario 11
  • Patty was on her way home from work and has been
    involved in a minor vehicle accident. There is
    minimal damage to the front end of her car. She
    has a small bump on her forehead.
  • Patty is 32 years old
  • Patty is alert and oriented x4. She denies any
    loss of consciousness. Her vital signs are
    within normal limits. She states she doesnt want
    to be transported to the hospital.

70
  • Can Patty refuse transport?
  • Does EMS need to contact Medical Control?
  • How should EMS proceed?
  • How would this scenario change if Patty had
    alcohol on her breath and tells EMS she has had 3
    glasses of wine?

71
Scenario 12
  • Katie is a 22-year old woman. Neighbors had
    called the ambulance because of a domestic
    disturbance. Police has not been dispatched at
    this point. Katie has an obviously deformed jaw,
    with an abrasion on her chin and pain opening and
    closing her mouth.

72
  • Katies husband states that she is fine and does
    not need to go to the hospital. Katie has a flat
    affect and is not communicating with EMS
    providers. She does not make eye contact.
  • EMS has called you for direction. Can Katie
    refuse treatment at this point?
  • What do you want to advise EMS to do?

73
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