Emergency Medical Services Division Draft Ross Elliott EMS Director Robert Barnes, M.D. Medical Director 1
Revision Log 01/01/1992 Initial draft 08/01/2013 POLST Addition Kern County Public Health Services Department, Emergency Medical Services Division Page 1
Table of contents I. PURPOSE... 3 II. AUTHORITY... 3 III. DEFINITIONS... 3 IV. BACKGROUND... 3 V. EMSA APPROVED DOCUMENTS... 4 A. Emergency Medical Services Authority (EMSA)/California Medical Association (CMA) Prehospital DNR Form 4 B. EMSA approved Physician Orders for Life Sustaining Treatment (POLST)... 5 C. Do Not Resuscitate Orders DNR:... 7 D. Durable Power of Attorney for Healthcare... 9 E. Declaration to Physicians or Living Will... 10 F. Cooperative Program between Kern County EMS Division, Kern County Medical Society, and Medic Alert:.. 11 G. The Medic Alert Program... 12 ix. Medic Alert Consent Form Specifics... 12 Kern County Public Health Services Department, Emergency Medical Services Division Page 2
I. PURPOSE A. These guidelines are intended to assist emergency medical services personnel dealing with Do Not Resuscitate (DNR) orders and Advanced Health Care Directives (AHCD) that honor patientdesignated choices regarding refusing unwanted resuscitation attempts and other out-of-hospital interventions. These policies allow patients to refuse unwanted resuscitation attempts and medical interventions and ensure that a patient s rights are honored. II. AUTHORITY A. Health and Safety Code Section 1797.220, 1798, Section 4780 of the Probate Code III. DEFINITIONS A. Advanced Directive : a legal document signed by a competent person to provide guidance for medical and health-care decisions in the event the person becomes incompetent to make such decision. B. Do Not Resuscitate (DNR) Orders: A DNR Form is an official document when completed correctly, allows a patient with a life threatening illness or injury to forgo specific resuscitative measures that may keep them alive. C. Living Will : A document in which the signer requests to not be resuscitated rather than be kept alive by artificial means if disabled beyond a reasonable expectation of recovery D. Physician Orders for Life-Sustaining Treatment (POLST) Form: An EMSA approved Physician Order Sheet that is based on the person s current medical condition and wishes. IV. BACKGROUND A. The goals of the emergency medical services personnel include saving lives, preventing disability and relieving suffering. Historically, this has meant treating patients to the fullest extent possible. More and more frequently, EMS personnel are faced with patients or families of patients who resist full resuscitative measures. These patients view resuscitative measures as causing unnecessary discomfort and emotional distress, without potential benefit. Quite often, these patients are victims of a terminal illness. They can be found in skilled nursing facilities, private residences, or under hospice care. B. EMS personnel have generally been obligated to initiate full resuscitative measures for all patients when the 9-1-1 emergency system has been activated, except where a base-station hospital physician directs to the contrary. This has forced terminally ill patients and their families to accept treatment they do not want. Kern County Public Health Services Department, Emergency Medical Services Division Page 3
C. Clearly, EMS pre-hospital personnel should take the necessary steps to acknowledge the patient s wishes in regard to resuscitation. To that end, following guidelines have been developed to address do not resuscitate orders and advanced directives to reflect the patient s right to selfdetermination. D. Despite pre-planning not to perform resuscitation, family members and employees of health of long-term facilities may activate 9-1-1 when death is imminent. If appropriate documentation is available, performing resuscitation against a patient s wishes in this case is inappropriate because it denies them real authority over their healthcare. V. EMSA APPROVED DOCUMENTS A. Emergency Medical Services Authority (EMSA)/California Medical Association (CMA) Prehospital DNR Form i. The EMSA/CMA Prehospital DNR Form means no chest compressions, defibrillation, endotracheal intubation, assisted ventilation, or cardio-tonic drugs. ii. iii. iv. The patient should receive all other care not identified above for all other medical conditions in accordance with Kern County Treatment Protocols. Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped and the patient is unconscious, ventilation should not be assisted. A DNR form should have the following components: a. The form should contain the patient s name. b. Requests must be signed and dated by a physician. c. Requests must be signed and dated by the patient or surrogate. d. No witness to the patient's or surrogate's signature is necessary. Ensuring appropriate informed consent is the responsibility of the attending physician, not the EMS system or prehospital provider. v. The DNR Form should be clearly posted or maintained near the patient in the home. a. A typical location might be in an envelope in a visible location near the patient's bed. b. Copies of the form are valid and will be honored. c. The patient or family should be encouraged to keep a copy in case the original is lost. d. The copy should be taken with the patient during transport. vi. In general, EMS personnel should see the written prehospital DNR Form unless the patient's physician is present and issues a DNR order. Kern County Public Health Services Department, Emergency Medical Services Division Page 4
vii. viii. Correct identification of the patient is crucial, but after a good faith attempt to identify the patient, the presumption should be that the identity is correct if documentation is present and the circumstances are consistent. There should be a properly completed standard EMSA/CMA DNR Form available with the patient. A witness who can reliably identify the patient is valuable. ix. A blank sample EMSA/CMA Prehospital DNR Form is contained in Appendix A. B. EMSA approved Physician Orders for Life Sustaining Treatment (POLST) i. EMS personnel who encounter the EMSA approved POLST form in the field should be aware of the different levels of care in Sections A and B of the form (Section C does NOT apply to EMS personnel). ii. Section A of the POLST applies only to individuals who do NOT have a pulse and are NOT breathing upon arrival of EMS personnel. a. If an individual has checked Attempt Resuscitation/CPR, then EMS personnel should treat the individual to the fullest extent possible according to Division Treatment Protocols regardless of what may be checked in Section B. For this individual this form as filled out does NOT constitute a DNR. b. If the individual has checked Do Not Attempt Resuscitation/DNR, then no attempts should be made to resuscitate the individual iii. Section B applies only to individuals who have checked Do Not Attempt Resuscitation/DNR in Section A AND who have a pulse and/or are breathing upon the arrival of EMS personnel. a. If an individual has checked Comfort Measures Only the following care, in accordance with Division paramedic treatment protocols, may be provided: 1. The patient should receive full palliative treatment for pain, dyspnea, major hemorrhage, or other medical conditions (includes medication by any route). 2. Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped and the patient is unconscious, ventilation should not be assisted. 3. Transfer patient to hospital only if comfort needs cannot be met in current location. Kern County Public Health Services Department, Emergency Medical Services Division Page 5
b. If an individual has checked Limited Additional Interventions the following care, in accordance with Division paramedic treatment protocols, may be provided (in addition to the care outlined above): 1. Administration of IV fluids. 2. May use non-invasive positive airway pressure to include: continuous positive airway pressure (CPAP) and bag valve mask (BVM) assisted respirations according to Kern County Protocol. This does NOT include intubation. 3. Transfer patient to hospital only if comfort needs cannot be met in current location. iv. If an individual has checked Full Treatment then they should be treated to the fullest extent possible in accordance of Kern County EMS Treatment Protocols. This includes, but is not limited to, intubation and other advanced airway interventions, mechanical ventilation and defibrillation/cardioversion. v. In the event that a properly filled out POLST form is present, the identity of the patient has been verified, the patient or documented patient representative is refusing transport and treatment in a manner consistent with section B is being considered, Base Contact shall be made via phone and a consult with a Base Station Physician shall take place. a. The physician orders shall give the appropriate course of treatment and indicate whether or not the physician wants the patient transported. b. Contact must be made while on scene and prior to treatment. c. The physician must be able to talk to the family, patient, or patient representative responsible for the patient s care (if present). d. Contact is preferred via phone and must be on a recorded line e. If phone contact with a base station physician fails or is not available transport is indicated in accordance with the Ambulance Destination Decision Policies and Procedures and no paramedic protocol based treatment is authorized without transport. vi. vii. viii. If a hospice patient, contact with the Hospice Nurse should be made to ensure treatment is in line with the ongoing care of the patient and to make sure comfort measures can be met at the current location. It is preferred the Hospice Nurse is present or responding to the scene. The patient or responsible party shall sign a Release of Liability if transport is refused or deemed inappropriate. There shall not be any conflict or unusual circumstances present; if so transport is indicated in accordance with Ambulance Destination Decision Policies and Procedures and no paramedic protocol based treatment is authorized without transport. The on-scene healthcare authority may unilaterally determine that these conditions are present. Kern County Public Health Services Department, Emergency Medical Services Division Page 6
ix. A copy of the POLST document should be included in the documentation if possible. The name of the physician who gave orders and the circumstances of the situation must be completely documented in accordance with Patient Care Record Policies and Procedures. x. In the event an individual s condition deteriorate after EMS personnel have arrived and they have indicated DNR in Section A, then resuscitation efforts should be attempted up to, but NOT including, chest compressions. Base contact should be made and termination of continued resuscitative efforts should be considered. xi. xii. xiii. xiv. xv. xvi. xvii. xviii. EMSA approved POLST forms must be signed and dated by a physician and the patient or legally recognized decision-maker. No witness to the patient's or legally recognized decision-maker's signature is necessary. Ensuring appropriate informed consent is the responsibility of the attending physician, not the EMS system or prehospital provider as outlined in the Determination of Death Policies and Procedures. The EMSA approved POLST form should be clearly posted or maintained near the patient. A typical location might be in an envelope in a visible location near the patient's bed. Copies of the form are valid and will be honored. The patient or family should be encouraged to keep a copy in case the original is lost. The copy should be taken with the patient during transports. In general, EMS personnel should see the written EMSA approved POLST form unless the patient's physician is present and issues a DNR order. Correct identification of the patient is crucial, but after a good faith attempt to identify the patient, the presumption should be that the identity is correct if documentation is present and the circumstances are consistent. A witness who can reliably identify the patient is valuable. There should be a properly completed EMSA approved POLST form available with the patient. EMS crews should attempt to keep the POLST form with the patient at all times. The document is transferrable and can become part of the medical record in the hospital setting as well. If two POLSTs are present, the most recently correctly filled out document should be considered the most current wishes of the patient. A blank sample EMSA approved POLST Form is contained in Appendix D C. Do Not Resuscitate Orders DNR: i. A valid DNR order consists of the following information: a. The patient s name b. The words do not resuscitate, no code, or no CPR Kern County Public Health Services Department, Emergency Medical Services Division Page 7
c. The physician s signature d. The date the order was written e. There are no other requirements for a DNR order such as a prescribed form, a time or date of duration, or a diagnosis. ii. iii. iv. A written telephone order in any licensed health care facility is considered valid. If the patient s physician is present he/she may verbally order a DNR. This must be followed immediately by a written DNR order in the medical record by the physician. A telephone order by the patient s physician to EMS personnel is not acceptable. DNR means no chest compressions, defibrillation, endotracheal intubation, or cadiotonic drugs. v. The patient should receive full treatment other than resuscitative measures airway, suctioning, control of pain and hemorrhage, etc. vi. vii. viii. ix. Airway techniques, such as the Heimlich Maneuver and bag-mask ventilation with oropharyngeal airways, may be employed on a temporary basis. Relief of choking caused by a foreign body is always appropriate. Great effort must be taken to correctly identify the patient. This will usually require the presence of a witness, especially a family member, who can make positive identification. Orders should be written, signed, and dated by a physician. The order must clearly state the words do not resuscitate, no code, no CPR, or other clear statement of intent by the physician. Assuring the appropriate informed consent is the responsibility of the patient s physician. If the patient is confined to a long-term care facility or hospice, the facility staff should have the patient s medical record with the DNR order recorded in it available for the prehospital personnel to see upon arrival. x. To be effective, a home DNR request form should be completely filled out, legible, and have the stamp of any required agency. Emergency personnel should see the written home DNR request form and not accept verbal orders unless the physician is present and executes a written order. xi. Base station hospital physicians retain full responsibility and authority for determining the appropriateness of resuscitation decisions and may countermand a DNR order. Emergency personnel in the field have the ability to notify a base station hospital of the details of a particular case, if resuscitation appears unwarranted or unwanted by the patient. While field circumstances make this type of ad hoc determination difficult as a routine procedure, it may apply to certain cases where the patient s wishes are known and explicitly expressed. Kern County Public Health Services Department, Emergency Medical Services Division Page 8
xii. xiii. xiv. xv. If the patient has a DNR order, is conscious, and states they wish resuscitative measures initiated, then the DNR orders should be ignored. If the patient has a DNR order, is unable to state their wishes and a family member direct resuscitative measures be initiated, then the DND order should be ignored. If the patient has a DNR order, is unable to state their wishes and a family member directs resuscitative measures be initiated, resuscitation should be undertaken until the situation is clarified. The DNR order or a copy shall be attached to the EMS Prehospital Record, along with complete and appropriate written documentation and forwarded to the base hospital and EMS Division. Advance directives such as the Durable Power of Attorney for Health Care and Living Will are not to be considered the equivalent of a DNR order, and as such may be problematic for use as a field directive to prehospital care personnel in the absence of a DNR order by the patient s physician. IF FOR ANY REASON THE DNR ORDER DOES NOT SEEM TO APPLY TO THE SITUATION, RESUSCITATION SHOULD BE INITIATED AND THE BASE HOSPITAL CONTACTED IMMEDIATELY. D. Durable Power of Attorney for Healthcare i. The durable power of attorney for health care is described in the California Civil Code Sections 2410-2444. This document allows the patient to appoint an attorney in fact to make health care decisions for the patient should they become incapacitated. The document also allows written specification of what types of treatment or resuscitation a patient would desire if they were able to make decisions for themselves. ii. iii. iv. Although this document can be lengthy, not all sections must be filled out. Health care providers respecting the decisions of the attorney in fact or written instructions contained in the durable power of attorney for healthcare are provided liability protection for the following the patient s wishes. Once properly executed, the durable power of attorney for healthcare is valid indefinitely, but it may be for a shorter period specified by the patient. However, it may be revoked by the patient at any time prior to its expiration date. Prehospital healthcare providers may honor the directives contained in the durable power of attorney, if the patient can be reasonably identified as that person who executed the directive. Resuscitative measures should be withheld if the directive so specifies. It should be anticipated that the directive may contain lay language such as, no life support, no code, no breathing machine, no breathing tubes, etc. Kern County Public Health Services Department, Emergency Medical Services Division Page 9
v. To be valid for use by EMS prehospital care providers, a durable power of attorney must have the following: a. Name and signature of the patient b. Two witness signatures or notary public endorsement c. Name of agent attorney in fact d. Date executed e. The situation under consideration fall within the time period covered by the document f. The patient s specific directives for healthcare interventions. g. The patient is incapacitated. vi. vii. viii. A durable power of attorney for healthcare may not contain any specific medical directives and relies solely upon the attorney in fact to make directives at the appropriate time. If the durable power of attorney contains no specific directives, then the attorney in fact identified in the document must be physically present and direct that no resuscitative efforts be provided for the patient. Otherwise, resuscitative efforts should be implemented. If the document specifically requests that no resuscitation be undertaken, and it can be reasonably concluded that the patient is the person who executed the document, then resuscitation should be withheld even if the attorney in fact is not present. If the interpretation of the document is unclear, and the attorney in fact is absent or unable to provide clear directives, then, resuscitative efforts should be implemented. E. Declaration to Physicians or Living Will i. Declarations to Physicians is found in the California Natural Death Act in Health and Safety Code Sections 7185-7195. This document allows a directive to physicians by adult patients directing the withholding or withdrawal of life-sustaining procedures in a terminal condition. ii. iii. The declaration only applies to incurable diseases or illness certified to be a terminal condition by two physicians where lifesaving procedures would only artificially prolong life, and requires that the patient not be pregnant at the time. The patient must have been diagnosed and notified of the terminal condition and the declaration must be witnessed by two individuals. The Living Will is any written statement in which a person states what treatment is desired or rejected. The Natural Death Act declaration is thus a form of Living Will. Usually however, the term is used for documents labeled Living Will, which do not meet the precise terms of California Statue; nevertheless, they may provide useful information regarding patient s wishes. No specific form is mandated and many groups have distributed their own versions. Kern County Public Health Services Department, Emergency Medical Services Division Page 10
F. Cooperative Program between Kern County EMS Division, Kern County Medical Society, and Medic Alert: i. Do Not Resuscitate (DNR) is a prehospital advance directive option receiving increasing public and medical attention for its importance and usefulness. In a cooperative program, the nonprofit Medic Alert Foundation, Kern County EMS Division, and Kern County Medical Society have created a special DNR program which allows patients to limit the scope of prehospital emergency medical care they receive if their heart stops beating or they stop breathing. The program provides physicians with materials for patients to prepare written DNR orders, and to obtain a Medic Alert wrist or neck emblem with an approved DO NOT RESUSCITATE-EMS inscription. ii. iii. iv. The most accurate form of identification for patients outside of licensed facilities is a medallion or bracelet attached to the patient. Use of such a medallion should never make the patient uncomfortable and should always be optional. Kern County Providers should accept the bracelet or medallion, which have controlled availability so that EMS personnel may immediately honor the medallion, by itself. Medallions should only be issued after receiving a copy of the completed EMSA/CMA approved DNR Request Form or the EMSA approved POLST Form from an individual. Should an individual use a POLST form to acquire their medallion the acronym POLST shall be inscribed on the medallion. Should EMS personnel encounter an individual with a DNR medallion, treatment should follow as outlined by the Kern County approved DNR guidelines. If the individual s medallion indicates POLST in addition to DNR then if the POLST form is available to the EMS personnel, treatment should follow as indicated on the POLST form. In the absence of a POLST form, when a DNR/POLST medallion is encountered, the EMS personnel should treat the individual in a manner consistent with that outlined by the Kern County Treatment Protocols until the individual s valid EMSA approved POLST form is produced. v. The emergency medical services system must not be used simply to pronounce death in nursing home patients. Inappropriate use of EMS Personnel simply to pronounce death of patients should be reported to the Division. DNR orders are aimed at patients who may suffer cardiac arrest during treatment or transfer. vi. Base hospital physicians retain authority for determining the appropriateness of resuscitation. EMS personnel in the field have the ability to contact a base hospital and advise the physician of the details of a particular case if resuscitation appears unwarranted or unwanted by the patient. While field circumstances make this type of ad hoc decision difficult as a routine procedure, it may still apply to specific cases where patients' wishes are known and explicitly expressed. Kern County Public Health Services Department, Emergency Medical Services Division Page 11
vii. viii. Physicians, emergency medical service personnel, and other healthcare providers must often decide about the resuscitation of critically ill patients without prior guidance from the patient. Pre-established guidelines on foregoing treatment in the event of a cardiac or respiratory arrest allow healthcare providers on the scene to best serve the patient s needs. Some people do not want to be sustained on life-support systems. Others prefer not to be resuscitated when their heart stops beating or they stop breathing. The program is intended for those patients who are of significantly advanced age or have an end-stage illness who, along with their physicians, have decided that aggressive prehospital care by EMS personnel is not in their best interest. A DNR order either on paper of in the Medic Alert emblem, indicates the expressed wishes of the patient if he/she can t speak for him/herself. G. The Medic Alert Program i. The DNR program consists of a three part consent form, signed by the patient and the patient s physician, and an engraved Medic Alert wrist or neck emblem. The Medic Alert emblem, inscribed with DO NOT RESUSCITATE-EMS or DO NOT RESUSCITATE-POLST is only available if the DNR consent form has the attending physician s signature and accompanies the Medic Alert enrollment application. The physician s signature and accompanies the Medic Alert enrollment application. The physician s signature provides an indication of informed consent, competence of the patient to sign of appropriateness of the request. ii. iii. iv. ix. The patient keeps the white copy of the DNR form and the canary copy of the form is kept in the patient s medical record. The consent form itself is acceptable documentation to EMS personnel. However, forms may become damaged or lost. To ensure patient s wishes are honored, an engraved Medic Alert emblem with the DNR designation, is recommended. If a Medic Alert emblem is desired, the pink copy of the DNR form and a completed Medic Alert enrollment form, must be sent to Medic Alert. The engraved Medic Alert emblem, with the DNR designation, alerts healthcare personnel to the patient s DNR wishes and physician order. The emblem is an internationally recognized symbol. Prehospital emergency care personnel are trained to look for and read the information about the DNR Program to area first responders and EMS personnel. By completing the DNR form and/or wearing the Medic Alert wrist or neck emblem with the authorized engraving, the patient clearly makes known his/her desire not to be resuscitated. Medic Alert Consent Form Specifics a. The DNR forms were specifically designed for patients wanting a DNR order. The form details that if the individual s heart stops beating or if he/she stops breathing, no medical procedure to restart hear function or breathing will be instituted by prehospital emergency personnel. The form further states that the DNR decision will not prevent the patient from obtaining other Kern County Public Health Services Department, Emergency Medical Services Division Page 12
emergency medical care by prehospital EMS personnel and/or medical care directed by a physician prior to death. b. The DNR order may be revoked at any time by destroying all DNR consent forms and removing any Medic Alert wrist or neck emblem worn by the patient. The order may also be revoked orally by the patient or by a base station emergency physician depending on medical circumstances. x. Benefits of Medic Alert a. The benefits of patient-directed DNR orders are several. The patient is able to fully determine his or her own treatment regimens. Caregivers including healthcare and EMS personnel, are more aware of the patient s wishes and may be able to provide more sensitive and nurturing care. b. A DNR order provides family members with an understanding of the patient s preferences about resuscitation, should a critical situation arise. Family members and/or legal surrogates can participate in the decision making process knowing the predetermined wish of the patient. c. You, as an EMS prehospital care provider as well as other healthcare professionals benefit. The potential for stress and conflict among staff is reduced, potential treatment can be anticipated, guidance may be more readily available from other professionals, obligations to patients are clearer, and legal risks and fears of unwarranted litigation may decrease. Kern County Public Health Services Department, Emergency Medical Services Division Page 13
APPENDIX A CALIFORNIA NATURAL DEATH ACT Kern County Public Health Services Department, Emergency Medical Services Division Page 14
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APPENDIX B MEDIC ALERT INFORMATION Kern County Public Health Services Department, Emergency Medical Services Division Page 19
APPENDIX C EMSA/CMA approved Prehospital DNR Form Kern County Public Health Services Department, Emergency Medical Services Division Page 20
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Appendix D EMSA approved POLST Form Kern County Public Health Services Department, Emergency Medical Services Division Page 22
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