1. State of Delaware Pre-Hospital Advanced Care Directive Regulations (PACD)

2. What is PACD? A Pre-Hospital Advanced Care Directive (PACD) allows terminally ill patients, upon discussion with their primary physician, the right to elect to either receive full, limited, or no resuscitative efforts by EMS field responders.

3. Living Wills Power of Attorney “DNR” “DNI” Prescription pad Family wishes Why Do We Need It?

4. Goals of the Regulation To eliminate the confusion To eliminate the confusion To mandate a specific form for the pre- hospital environment To mandate a specific form for the pre- hospital environment Establish guidelines for different levels of care Establish guidelines for different levels of care Detail the immunity for providers honoring the request Detail the immunity for providers honoring the request

5. How Long Have We Had It? Introduced November 1, 2002 Introduced November 1, 2002 Public comment period – November 26 th through December 31 st Public comment period – November 26 th through December 31 st Effective Date – July 10, 2003 Effective Date – July 10, 2003

6. Specific Form Delaware Health and Social Services Division of Public Health Pre-Hospital Advanced Care Directive (PACD) For Terminal Illness Only Scope of Emergency Medical Services Care

7. What Does It Look Like?

8. What Are Our Responsibilities? Primary Care Physicians Primary Care Physicians –Explaining the form to their terminally ill patients –Explaining the options of pre-hospital care –Helping the patient select the option they desire –Helping the patient fill out both the form and wallet card –Keeping a copy of the PACD form in the patient’s medical records. EMS Field Responders EMS Field Responders –Locating the signed PACD form –Determining its validity –Adhering to the option of care chosen

9. Three Options The patient may choose from three levels of care The patient may choose from three levels of care Each level defines specific treatment options Each level defines specific treatment options

10. Option A Advanced Life Support Maximal (Restorative) Care Before Arrest, Then DNR If pulse present, full scope of restorative interventions permissible under the Delaware Statewide ALS treatment protocols If pulse present, full scope of restorative interventions permissible under the Delaware Statewide ALS treatment protocols Upon cardiac arrest all efforts shall cease. Upon cardiac arrest all efforts shall cease.

11. Option B Basic Life Support Limited (Palliative) Care Only Before Arrest, Then DNR If pulse present, EMS will provide “comfort care” for control of signs and symptoms If pulse present, EMS will provide “comfort care” for control of signs and symptoms Upon cardiac arrest no further care. Upon cardiac arrest no further care.

12. Palliative Care EMS WILL provide: Opening Airway –J–J–J–Jaw thrust –H–H–H–Head-tilt chin lift –F–F–F–Finger sweep –O–O–O–OPA / NPA Oxygen Suctioning Control of bleeding Fracture immobilization Positioning Pain meds may be administered only by family or another HCP

13. Palliative Care EMS WILL NOT Perform Pacing Pacing Cardioversion Cardioversion Defibrillation Defibrillation Initiation of IV therapy Initiation of IV therapy EMS Meds (except O 2 ) EMS Meds (except O 2 ) CPR CPR PASG PASG Intubation Intubation –ETT –Combi-tube –LMA Gastric Tube Gastric Tube Active ventilatory assistance unless on a ventilator Active ventilatory assistance unless on a ventilator

14. Option C Do Not Resuscitate (DNR) No Care Administered of Any Kind No care of any kind will be given by EMS unless the patient wishes to revoke the PACD No care of any kind will be given by EMS unless the patient wishes to revoke the PACD

15. “I’ve changed my mind” The patient and only the patient may revoke this at anytime by providing some sort of communication to the care providers. - Verbally - Eye Blinking - Finger Tapping - Any other form of communication to indicate a desire to revoke the PACD

16. The PACD Form Must be signed and dated by the patient and the primary care physician. Must be signed and dated by the patient and the primary care physician. The patient and physician name, address and phone number must be printed. The patient and physician name, address and phone number must be printed. Must denote the Option of Care selected Must denote the Option of Care selected If the form is incomplete it is invalid.

17. Record-Keeping Original document is kept w/patient’s permanent medical records/files at the facility providing primary care Original document is kept w/patient’s permanent medical records/files at the facility providing primary care –Physician’s office –Hospital –Nursing Home –Other health care provider facility. A copy is kept w/patient A copy is kept w/patient –at the patient’s home, or –at the health care facility where patient is admitted and receiving medical care/treatment

18. Wallet Card The purpose of the wallet card is to alert emergency field personnel to the fact that a signed PACD form exists The purpose of the wallet card is to alert emergency field personnel to the fact that a signed PACD form exists EMS Providers MAY NOT honor the wallet card alone EMS Providers MAY NOT honor the wallet card alone We MUST have the signed PACD form in order to honor the PACD We MUST have the signed PACD form in order to honor the PACD

19. Documentation We will document that we saw the form and desired option in the EDIN report We will document that we saw the form and desired option in the EDIN report We will document that the form found at the scene was turned over to the hospital for inclusion in the patient’s record, or We will document that the form found at the scene was turned over to the hospital for inclusion in the patient’s record, or That the form was retained by the EMS agency for their records That the form was retained by the EMS agency for their records –DOPA or other non-transports If the patient revokes the PACD, the revocation and how it was communicated will be documented If the patient revokes the PACD, the revocation and how it was communicated will be documented

20. Liability EMS is included in the immunity provisions of the State’s Health-Care Decision regulations as a result of withholding or withdrawing any health care.

21. Common Questions Q - What if the nursing home only has their DNR paperwork? A – We can only recognize the state approved PACD form. We will contact medical control for guidance if presented with another form of DNR order

22. Common Questions Q – What if the form is not completed? A – We can only honor the form if it is complete. Otherwise, we will provide full EMS care and contact medical control for further guidance.

23. Q – What if the patient is injured and not dying from their terminal illness? Common Questions A –If the terminally ill patient is injured, the PACD will be followed in accordance with the option selected.

24. Q – What happens with an Out of State DNR? Common Questions A – Standardized EMS DNR orders from another state approved by the Director of the Division of Public Health shall be honored and treated as Option B (Palliative Care Only).

25. Questions