Hostname: page-component-7479d7b7d-767nl Total loading time: 0 Render date: 2024-07-13T04:46:05.582Z Has data issue: false hasContentIssue false
  • English
  • Français

Do-Not-Resuscitate Orders: Where Are They in the Prehospital Setting?

Published online by Cambridge University Press:  28 June 2012

Kristi L. Koenig  and
Gary W. Tamkin
Kristi L. Koenig*
Affiliation:
Emergency Department, Highland General Hospital, Oakland, Calif.
Gary W. Tamkin
Affiliation:
Emergency Department, Highland General Hospital, Oakland, Calif.
*
Emergency Department, Highland General Hospital, 1411 East 31st Street, Oakland, CA 94602USA
Get access Rights & Permissions [Opens in a new window]

Abstract

Without a well-functioning, prehospital, do-not-resuscitate (DNR) system in place, emergency medical service (EMS) providers must resuscitate all patients who access the system, regardless of the patients' wishes and regardless of what makes ethical or economic sense. In lieu of valid documentation, it is not appropriate to withhold resuscitative measures in this critical, time-dependent situation. In order to help EMS systems implement functional prehospital DNR protocols, this paper reviews the state-of-the-art of prehospital DNR including the issues to consider when designing such a system and a discussion of the features of some of the existing systems. This review includes: 1) the basis and requirements of a DNR system; 2) legal and physical forms for DNR orders; 3) eligibility for DNR status; 4) reversal of DNR orders; and 5) inappropriate use of EMS systems for DNR patients. Finally, a more general discussion of overall resource utilization in prehospital resuscitations is presented to emphasize that implementing prehospital DNR systems is only one piece of a larger issue.

Keywords

advance directivescost-containmentdo-not-resuscitate ordersemergency medical servicesethicsprehospitalresource utilizationresuscitationterminal illness
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 8 , Issue 1 , March 1993 , pp. 51 - 54
Copyright
Copyright © World Association for Disaster and Emergency Medicine 1993

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. La Puma, J, Silverstein, MD, Stocking, CB, et al. : Life sustaining treatment: A prospective study of patients with DNR orders in a teaching hospital. Arch Intern Med 1988;148:2193–2198.CrossRefGoogle ScholarPubMed
2. Tamkin, G: National survey of prehospital care for the terminally ill. Senior honors thesis, Brown University Department of Community Health, 1986.Google Scholar
3. Standards and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care. JAMA 1986;255:2841–3044.Google Scholar
4. Wilcox, DP: Withholding resuscitation: The physician's responsibility. Tex Med 1981;77:72–73.Google ScholarPubMed
5. American Medical Association: Current Opinions of the Judicial Council of the American Medical Association. Chicago: AMA, 1986.Google Scholar
6. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Deciding to Forego Life-Sustaining Treatment. Washington, D.C.: U.S. Government Printing Office, 1983.Google Scholar
7. Joint ad hoc committee on biomedical ethics of the Los Angeles County Medical Association and Los Angeles County Bar Association: Guidelines for Discontinuance of Cardiopulmonary Life Support Systems Under Specified Circumstances. Los Angeles: LACMA and LACBA, 1981.Google Scholar
8. Evans, AL, Brody, BA: The do-not-resuscitate order in teaching hospitals. JAMA 1985:253:2236–2239.CrossRefGoogle ScholarPubMed
9. Lipton, HL: Do-not-resuscitate decisions in a community hospital. JAMA 1986; 256:1164–1169.CrossRefGoogle Scholar
10. Siner, DA: Advance directives in emergency medicine: Medical, legal, and ethical implications. Ann Emerg Med 1989; 18:1364–1368.CrossRefGoogle Scholar
11. Sachs, GA, Miles, SH, Levin, RA: Limiting resuscitation: Emerging policy in the emergency medical system. Ann Int Med 1991;114:151–154.CrossRefGoogle ScholarPubMed
12. California Senate Bill 1797 (Senator Thompson): The Do Not Resuscitate Act of 1992.Google Scholar
13. Faber-Langendoen, K: Resuscitation of patients with metastatic cancer: Is transient benefit still futile? Arch Intern Med 1991:151:235–239.CrossRefGoogle ScholarPubMed
14. Gamble, ER, McDonald, PJ, Lichstein, PR: Knowledge, attitude, and behavior of elderly persons regarding living wills. Arch Intern Med 1991;151:277–281.CrossRefGoogle ScholarPubMed
15. Minutes of the Emergency Medical Directors Association of California (EMDAC) meeting. San Francisco, 11 June 1992.Google Scholar
16. Byock, I: Letter to the editor: DNR orders and living wills. Ann Emerg Med 1989:18:911–912.CrossRefGoogle Scholar
17. Strange, GR, Flynn, RJ, Whitehall, J: Ethical considerations in emergency department management of terminally ill patients. Ann Emerg Med 1989:18:1085–1088.CrossRefGoogle ScholarPubMed
18. Lewis, LM, Ruoff, B, Rush, C, Stothert, JC: Is emergency department resuscitation of out-of-hospital cardiac arrest victims who arrive pulseless worthwhile? Am J Emerg Med 1990;8:118–120.CrossRefGoogle ScholarPubMed
19. Silfvast, T: Initiation of resuscitation in patients with prehospital bradyasystolic cardiac arrest in Helinski. Resuscitation 1990;19:143–150.CrossRefGoogle Scholar
20. Tresch, DD, Thakur, RK, Hoffmann, RG, et al. : Should the elderly be resuscitated following out-of-hospital cardiac arrest? Am J Med 1989;86:145–149.CrossRefGoogle ScholarPubMed
21. Bonnin, MJ, Swor, RA: Outcomes in unsuccessful field resuscitation attempts. Ann Emerg Med 1989:18:507–511.CrossRefGoogle ScholarPubMed
22. Valenzuela, TD, Criss, EA, Spaite, D, et al. : Cost effectiveness analysis of paramedic emergency medical services in the treatment of pre hospital cardiopulmonary arrest. Ann Emerg Med 1990;19:1407–1411.CrossRefGoogle Scholar
23. Murphy, MJ, Matchar, DB: Life sustaining therapy: A model for appropriate use. JAMA 1990;264:2103–2107.CrossRefGoogle Scholar