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 person’s 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 determine that the legal paperwork is legal paperwork is sufficient to halt sufficient to halt resuscitative measures 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.

14. 2013 IDPH Form  To find a copy of the form go to –www.idph.state.il.us 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 patient’s 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 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  > 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

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.

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 patient’s 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 physician’s 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@presencehealth.org Mary.butzow@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 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 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  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 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 doesn’t 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.  Katie’s 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?