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Implementation of a novel prehospital advance directive protocol in southeastern Ontario

Published online by Cambridge University Press:  21 May 2015

Rose P. Mengual ,
Michael J. Feldman  and
Gord R. Jones
Rose P. Mengual*
Affiliation:
Department of Emergency Medicine, Dalhousie University, Halifax, NS
Michael J. Feldman
Affiliation:
Division of Emergency Medicine, University of Toronto and the Sunnybrook-Osler Centre for Prehospital Care, Toronto, Ont.
Gord R. Jones
Affiliation:
Department of Emergency Medicine, Queen's University, Kingston, Ont.
*
Room 3021, Halifax Infirmary, Queen Elizabeth II Health Sciences Centre, 1796 Summer Street, Halifax NS B3H 3A7; rose_mengual@hotmail.com

Abstract

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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.

Keywords

prehospital careparamedicsemergency medical servicesadvance directivesdo-not-resuscitate ordersethicscardiac arrest
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 9 , Issue 4 , July 2007 , pp. 250 - 259
Copyright
Copyright © Canadian Association of Emergency Physicians 2007

References

1.Health Care Consent Act. Part II, c. 2. Sched. A. Sections 20 and 21. Toronto (ON): Ontario Ministry of Health and LongtermCare; 1996. Available: http://www.e-laws.gov.on.ca/DBLaws/Statutes/English/96h02_e.htm (accessed 2006 May).Google Scholar
2.Regulated Health Professions Act. c. 18. Section 44. Sched. 1. Toronto: Ontario Ministry of Health and Longterm Care; 1991. Available: http://www.e-laws.gov.on.ca/DBLaws/Statutes/English/91r18_e.htm (accessed 2006 May).Google Scholar
3.Anonymous, . Emergency medical services need not resuscitate. Nurs Manage 1996;27:50–2.Google Scholar
4.Crimmins, TJ. Communicating DNR ordersto ambulance personnel. Minn Med 1991;74:33–5.Google Scholar
5.Fitzgerald, DJ, Milzman, DP, Sulmasy, DP. Creating a dignified option: ethical considerations in the formulationof a prehospital DNR protocol. Am J Emerg Med 1995;13:223–8.CrossRefGoogle ScholarPubMed
6.In and out of hospital DNR. Tex Nurs 1997;71:12–4.Google Scholar
7.Iserson, KV. A simplified prehospital advance directive law: Arizona’s approach. Ann Emerg Med 1993;22:1703–10.CrossRefGoogle ScholarPubMed
8.Kellermann, AL. Criteria for dead-on-arrivals, prehospital termination of CPR, and do-not-resuscitate orders. Ann Emerg Med 1993;22:47–51.CrossRefGoogle ScholarPubMed
9.Leon, MD, Wilson, EM. Development of a statewide protocol for the prehospital identification of DNR patients in Connecticut including new DNR regulations. Ann Emerg Med 1999;34:263–74.CrossRefGoogle ScholarPubMed
10.Lerner, EB, Billittier, AJ, Hallinan, K. Out-of-hospital do-not-resuscitate orders by primary care physicians. J Emerg Med 2002;23:425–8.Google Scholar
11.Rausch, PG, Ramzy, AI. Development of a palliative care protocol for emergency medical services. Ann Emerg Med 1991;20:1383–6.CrossRefGoogle ScholarPubMed
12.Schmidt, TA, Hickman, SE, Tolle, SW, et al. The physician orders for life-sustaining treatment program: Oregon emergency medical technicians’ practical experiences and attitudes. J Am Geriatr Soc 2004;52:1430–4.Google Scholar
13.Sosna, DP, Christopher, M, Pesto, MM, et al. Implementation strategies for a do-not-resuscitate program in the prehospital setting. Ann Emerg Med 1994;23:1042–6.CrossRefGoogle ScholarPubMed
14.Travers, DA, Mears, G. Physicians’ experiences with prehospital do-not-resuscitate orders in North Carolina. Prehospital Disaster Med 1996;11:91–100.CrossRefGoogle ScholarPubMed
15.Adams, JG. Prehospital do-not-resuscitate orders: a survey of state policies in the United States. Prehospital Disaster Med 1993;8:317–22.Google Scholar
16.Sachs, GA, Miles, SH, Levin, RA. Limiting resuscitation: emerging policy in the emergency medical system. Ann Intern Med 1991;114:151–4.CrossRefGoogle ScholarPubMed
17.Sabatino, CP. Survey of state EMS-DNR laws and protocols. J Law Med Ethics 1999;27:297–316.Google Scholar
18.Schears, RM, Marco, CA, Iserson, KV. “Do not attempt resuscitation” (DNAR) in the out-of-hospital-setting. Ann Emerg Med 2004;44:68–70.CrossRefGoogle ScholarPubMed
19.Koenig, KL, Tamkin, GW. Do-not-resuscitate orders: where are they in the prehospital setting? Prehospital Disaster Med 1993;8:51–5.CrossRefGoogle ScholarPubMed
20.Iserson, KV. Prehospital advance directives — a better way. J Emerg Med 2002;23:419–20.CrossRefGoogle ScholarPubMed
21.Innes, G, Wanger, K. Dignified death or legislated resuscitation? CMAJ 1999;161:1264–5.Google Scholar
22.Harlos, M, Verbeek, PR, Morrison, LJ. Prenotification in cases of death in the home – two of the authorsrespond. CMAJ 2000; 162:631.Google Scholar
23.Pauls, M. Prehospital DNR orders: an ethical dilemma. Can J Emerg Med 2001;3:6.CrossRefGoogle Scholar
24.Feder, S, Matheny, RL, Loveless, RS, et al. Withholding resuscitation: a new approach to prehospital end-of-life decisions. Ann Intern Med 2006;144:634–40.CrossRefGoogle ScholarPubMed
25.Ontario Ministry of Health and Longterm Care EHS Branch. Inter-facility do notresuscitate orders. Basic life support patient care standards (1.1). The Ministry. 1995. Appendix 59A-1.Google Scholar
26.Guru, V, Verbeek, PR, Morrison, LJ. Response of paramedics to terminally ill patients with cardiac arrest: an ethical dilemma. CMAJ 1999;161:1251–4.Google Scholar
27.Hwang, JP, Smith, ML, Flamm, AL.Challenges in outpatient end-of-life care: wishes to avoid resuscitation. J Clin Oncol 2004;22:4643–5.Google Scholar
28.Iserson, KV, Rouse, F. Prehospital DNR orders. Hastings Cent Rep 1989;19:17–24.CrossRefGoogle ScholarPubMed
29.Partridge, RA, Virk, A, Sayah, A, et al. Field experience with prehospital advance directives. Ann Emerg Med 1998;32:589–93.CrossRefGoogle ScholarPubMed
30.Marco, CA, Schears, RM. Prehospital resuscitation practices: a survey of prehospital providers. J Emerg Med 2003;24:101–6.CrossRefGoogle ScholarPubMed
31.Iserson, KV, Stocking, C. Standards and limits: emergency physicians’ attitude toward prehospital resuscitation. Am J Emerg Med 1993;11:592–4.Google Scholar
32.Gordon, NP, Shade, SB. Advance directives are more likely among seniors asked about end-of-life care preferences. Arch Intern Med 1999;159:701–4.CrossRefGoogle ScholarPubMed
33.Emanuel, LL, Barry, MJ, Stoeckle, JD, et al. Advance directives for medical care — a case forgreater use. N Engl J Med 1991;324:889–95.CrossRefGoogle Scholar
34.Stelter, KL, Elliott, BA, Bruno, CA. Living will completion in older adults. Arch Intern Med 1992;152:954–9.Google Scholar
35.Gross, MD. What do patients express as their preferences in advance directives? Arch Intern Med 1998;158:363–5.Google Scholar
36.Taylor, D, Ugoni, AM, Cameron, PA, et al. Advance directives in emergency department patients: ownership rates and perceptions of use. Intern Med J 2003;33:586–92.CrossRefGoogle ScholarPubMed
37.Ishihara, KK, Wrenn, K, Wright, SW, et al. Advance directives in the emergency department: too few, too late. Acad Emerg Med 1996;3:50–3.CrossRefGoogle ScholarPubMed
38.Llovera, I, Mandel, FS, Ryan, JG, et al. Are emergency department patients thinking about advance directives? Acad Emerg Med 1997;4:976–80.Google Scholar
39.Iserson, KV. If we don't learn from history...: ethical failings in a new prehospital directive. Am J Emerg Med 1995;13:241–2.CrossRefGoogle Scholar
40.Ethics Committee, National Association of Emergency Medical Services Physicians. Ethical challenges in emergency medical services. Prehospital Disaster Med 1993;8:179–82.CrossRefGoogle Scholar
41.Jecker, NS, Schneiderman, LJ. Ceasing futile resuscitation in the field: ethical considerations. Arch Intern Med 1992;152:2392–7.Google Scholar
42.Van Stralen, D, Perkin, RM. Do not resuscitate, but do not forget comfort. Am J Emerg Med 1995;13:93–4.CrossRefGoogle ScholarPubMed