Dead or Alive? Resuscitation Decisions Presence Regional EMS

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  Describe situations in which the criteria for Field Death Declaration is applicable

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. EMS Providers must be well aware of patient/family rights in these difficult situations.

Protocols and Policies Refer to Region 6 Protocols for: –Do Not Resuscitate  Physician Orders for Life-Sustaining Treatment (POLST) –Termination of Resuscitation –Triple Zero –Field Death Declaration

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

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

 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

 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.

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

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.

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

2013 IDPH Form  To find a copy of the form go to – –Click on A to Z –Look up Do Not Resuscitate form

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

 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  ** More later

 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

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

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

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

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

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.

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

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

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

Whenever a patient with a DNR  Is not in cardiac arrest  Treat appropriately according to applicable protocol

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

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

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

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)

 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.

Remember  EMS must call the local coroner  Stay with the patient until relieved by coroner or local law enforcement

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

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

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)

Criteria for Field Death Declaration  > 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 or “No Shock Indicated” on AED Asystole or Idioventricular Rhythm  MAY BE WARM WITHOUT RIGOR OR LIVIDITY

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.

How should EMS to proceed?

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

 Put patient on the monitor to look for a viable rhythm

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

Remember  EMS must call the local coroner  Stay with the patient until relieved by coroner or local law enforcement

Summary  Know your policies and protocols regarding end of life/ resuscitation decisions.  EMS must always notify Medical Control for documentation on a recorded line and guidance.  EMS must call the coroner

Review  Consider the following questions as a group. –IDPH site code: Use site code assigned to your agency for  If doing this CE individually, please your answers to: –Use “Resuscitation Decisions 2014 CE” in subject box. –IDPH site code: E-1214W  You will receive an confirmation. Print this confirmation for your records and document in your PREMSS CE record book.

Question 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?

Question 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?

Question 3  Mary Jane’s mother has cardiac arrested. Mary Jane thinks her mom has a living will, but she can’t find it. She has never heard of a durable power of attorney. What should EMS do?

Question 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?

Question 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 EMS Providers do?

Question 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. As a transport paramedic agency what should you do now?

Question 7  Mike’s father is in cardiac arrest. Mike says he has durable power of attorney, but he can’t prove it with paperwork. He says his father is a DNR but he has no written order. He wants CPR stopped. What should EMS providers do?

Question 8  Mrs. Smith 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 EMS do?

Question 9  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. Does this child meet Field Death Declaration? Why or Why not?

Question 10  Eric’s mom is in the Hospice program for emphysema. She has a valid DNR signed by her, her doctor and Eric. Eric’s 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 EMS do?

Answers 1.Yes 2.Yes 3.Begin resuscitation (CPR) and call Medical Control for guidance 4.She does not meet criteria because of hypothermia, “ you aren’t dead until you are warm and dead”. 5.Begin resuscitation (CPR) and call Medical Control for guidance 6.Begin resuscitation (CPR) and call Medical Control for guidance regarding permission to halt resuscitation

7.Continue resuscitation (CPR) and call Medical Control for guidance. 8.Continue resuscitation (CPR) and call Medical Control for guidance regarding permission to halt resuscitation 9.No, the patient is a child (under age 14) and was not found pulseless and not breathing. 10.Begin resuscitation (CPR) and call Medical Control for guidance.