Introduction
Emergency medical technicians (EMTs) at all levels, including Paramedics, are required to provide emergency care and to transport patients to appropriate health care facilities. EMS personnel are further required to provide treatment to the fullest extent possible, subject to their level of training. However, more and more patients, where it is medically appropriate, are opting not to be resuscitated. Many patients arrange with their physician, nurse practitioner or physician assistant for a Do Not Resuscitate (DNR) order -- an order directing that the individual not be resuscitated in the event of cardiac or respiratory arrest.
This Comfort Care / DNR ("CC/DNR") Order Verification Protocol is designed to allow EMTs and first responders to honor a DNR order in an out-of-hospital setting. Before it came into being, there was no mechanism to enable EMS personnel to recognize DNR orders in out-of-hospital settings. EMS personnel were thus always obligated to perform full resuscitative measures when encountering a patient unable to convey directions regarding medical treatment, due to the patient being either unconscious or not competent, and the difficulty of ascertaining the validity of wishes asserted by family members or other witnesses on scene, under emergency conditions. Usually there is no ongoing relationship between the EMS personnel and the patient. Emergency conditions require an immediate response and accurate identification. Authentication of individuals and legal documents is difficult, if not impossible, under emergency field conditions, and placed an inappropriate burden on EMTs and first responders.
The Comfort Care/DNR, or CC/DNR protocol provides for a statewide, uniform DNR order verification, issued by the Massachusetts Department of Public Health (DPH), Office of Emergency Medical Services (OEMS), that EMTs and first responders can instantly recognize as an acceptable verification of an existing DNR order. It is not a DNR order itself, but allows EMTs and first responders to honor a patient's request for no resuscitation, as documented in a valid DNR, and to provide the patient with palliative care in conformance with the Comfort Care protocol.
Purpose
The purpose of this protocol is to: (1) provide a verification/authentication of DNR orders to enable EMTs and first responders to honor DNR orders in out-of-hospital settings; (2) clarify the role and responsibilities of EMTs and first responders at the scene and/or during transport of patients who have a current, valid CC/DNR Order Verification; (3) avoid resuscitation of patients who have a current, valid CC/DNR Order Verification; and (4) provide palliative/comfort care measures for patients with a current, valid CC/DNR Order Verification. This protocol does not alter the standard of practice in issuing DNR orders in any way, but only provides a standardized mechanism for the verification of the DNR order so that it may be recognized in out-of-hospital settings.
Definitions
For purposes of this protocol, the following are defined:
1. Attending Physician: A physician, licensed pursuant to M.G.L. c.112 §2, selected by or assigned to a patient, who is responsible for the treatment and care of the patient, in whatever setting medical diagnosis or treatment is rendered. Where more than one physician shares such responsibility, any such physician may act as the attending physician for purposes of this protocol.
2. Authorized Nurse Practitioner ("Authorized NP"): A registered nurse in the Commonwealth with advanced nursing knowledge and clinical skills as required by M.G.L. c. 112, § 80B and 244 CMR 4.00 et seq. A nurse practitioner may write a DNR order, where this activity is agreed upon by the nurse practitioner and the collaborating physician in written practice guidelines (244 CMR 4.22 (1)). It is the obligation of the nurse practitioner, the collaborating physician, and the institution where the nurse practitioner is practicing at the time the CC/DNR is issued to ensure that the nurse practitioner is authorized under his/her written practice guidelines to write a DNR Order and by extension to sign the Comfort Care Verification form.
3. Authorized Physician Assistant ("Authorized PA"): A person who meets the requirements for registration set forth in M.G.L. c. 112, § 9I, and who may provide medical services appropriate to his or her training, experience and skills under the supervision of a registered physician. The Board of Registration provides that a physician assistant may write DNR orders if : (1) his/her supervising physician determines that issuing a DNR order is within the competence of the physician assistant given the physician assistant's level of training and expertise (263 CMR 5.04 (1)), and (2) with regard to initial DNR orders, the physician assistant must consult with his/her supervising physician prior to issuance. A physician assistant may properly review and renew a preexisting DNR order without prior consultation with his/her supervising physician. Since the Comfort Care/Do Not Resuscitate Order Verification is a verification of an existing valid DNR order, the signing of the verification is comparable to the renewal of a preexisting DNR order. It is the obligation of the physician assistant, his/her supervising physician, and the institution where the physician assistant is practicing at the time the CC/DNR is issued to ensure that the physician assistant is authorized under his/her practice guidelines to write a DNR order and by extension to sign the Comfort Care Verification form.
4. Cardiopulmonary Resuscitation ("CPR"): Includes for purposes of this protocol, cardiac compression, artificial ventilation, oropharyngeal airway (OPA) insertion, advanced airway management such as endotracheal intubation, cardiac resuscitation drugs, defibrillation and related procedures.
5. Comfort Care / DNR Order Verification Form ("form"): A standardized statewide form for verification of DNR orders in the out-of-hospital setting, approved by the Department of Public Health. The CC/DNR Order Verification Form shall include the patient's name; date of birth; gender; address; date of issuance and date of expiration, if any, of the underlying DNR order; the signature and telephone number of an attending physician, authorized nurse practitioner, or authorized physician assistant; and the signature of the patient, guardian or health care agent. The CC/DNR Order Verification Form is the only DNR document that EMS personnel will be instructed to honor and can only be issued by an attending physician, authorized nurse practitioner, or authorized physician assistant.
6. Comfort Care / DNR Order Verification Protocol: A standardized statewide patient care protocol, part of the Statewide Treatment Protocols, to be followed by EMTs and first responders when encountering a patient with a current, valid CC/DNR Order Verification Form, whether an original or a copy. The protocol provides that the patient in respiratory or cardiac distress will receive palliative, comfort care consistent with the scope of the EMT's training and certification, but no resuscitative measures. The protocol applies to all emergency medical services personnel (Basic, Intermediate and Paramedic EMTs, as well as first responders) operating in an out-of-hospital setting, and requires that they perform patient assessment and treatment in accordance with this protocol.
7. Emergency Medical Services Personnel: Any EMT certified pursuant to 105 CMR 170.000 et seq. and any first responder as defined in 105 CMR 171.050.
8. Guardian: An individual appointed by the court, pursuant to M.G.L. c. 201, §§ 6, 6A, or 6B, to make decisions for a person who is mentally ill, mentally retarded or unable to make or communicate informed decisions due to physical incapacity or illness, provided that the appointment as guardian includes the right to make health care decisions; or, a parent or other individual who is legally entitled to make decisions about the care and management of a child during his/her minority.
9. Health Care Agent: An individual authorized by a health care proxy to make health care decisions on behalf of the principal, pursuant to M.G.L. c. 201D. The authority of the health care agent becomes effective only upon a written determination of the attending physician, pursuant to M.G.L. c. 201D, § 6, that the principal lacks the capacity to make or to communicate health care decisions.
10. Life-sustaining procedure: Cardiopulmonary resuscitation, as defined in number 4 above. Life-sustaining procedures shall not include any medical procedure or intervention considered necessary by the health care provider, EMS personnel, or the medical control physician to provide comfort care or to alleviate pain.
11. Medical Control Physician: A physician designated within the EMS system to provide on-line and off-line medical direction to EMS personnel.
12. Palliative care: Comfort care that eases or relieves symptoms without correcting the underlying cause or disease.
13. Out-of-hospital: Any setting outside a hospital where EMS personnel may be called and may encounter patients with CC/DNR Order Verifications including, but not limited to, long-term care, hospice, assisted living, private homes, schools, inter-facility transport, and other public areas.
Authority
It is well settled in Massachusetts that individuals, while competent, have the right to determine the course of their medical treatment, including the right to refuse medical treatment and to make end of life decisions. Norwood Hospital v. Munoz, 409 Mass. 116, 564 N.E.2d 1017 (1991); Brophy v. New England Sinai Hospital, 398 Mass. 417, 497 N.E.2d 626 (1986); Lane v. Candura, 6 Mass. App. Ct. 377, 376 N.E.2d 1232 (1978); and Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977). Similarly, it is recognized that incompetent individuals have the same right to determine the course of their medical treatment as well as to refuse medical treatment. Brophy v. New England Sinai Hospital, supra; Saikewicz, supra; Matter of Spring, 380 Mass. 629, 405 N.E.2d 115 (1980). See also, Matter of Dinnerstein, 6 Mass. App. Ct. 466, 380 N.E.2d 134 (1978); and Care and Protection of Beth, 412 Mass. 188, 587 N.E.2d 1377 (1992). As an extension of the health profession into the field, the emergency medical system has the same obligation to recognize an individual's right to refuse medical treatment in an out-of-hospital setting, where the authenticity of the documentation can be validated.
Further authority: M.G.L. c. 111C and 105 CMR 170.000 et seq.; M.G.L. c. 111 § 201 and 105 CMR 171.000 et seq.
Implementation Procedures
Eligibility: Anyone with a current valid DNR order is eligible for a CC/DNR Order Verification Form, including minors.
A DNR order is an order, executed by a physician, authorized nurse practitioner, or authorized physician assistant, issued according to the current standard of care. The standard for issuing the DNR order is neither defined nor changed by this protocol. This protocol simply serves to verify, for EMS personnel, a DNR Order issued according to the current standard of care.
Validity: To assure that a DNR order is recognized in any out-of-hospital setting, an attending physician, authorized nurse practitioner, or authorized physician assistant must provide a patient, who has a current DNR order, with a fully executed CC/DNR Order Verification. Pursuant to this protocol, EMS personnel will be instructed to honor a current valid CC/DNR Order Verification Form (either an original or a copy). Patients without CC/DNR Order Verification Form will be resuscitated by EMS personnel in accordance with standard EMS protocols.
Content: The CC/DNR Order Verification Form shall include:
- the name, date of birth, gender, and address of the patient;
- the name of the guardian or health care agent, if any;
- the signature of the patient or of the guardian or health care agent;
- verification by the attending physician, authorized nurse practitioner, or authorized physician assistant, of the existence of a current valid DNR order;
- the signature and telephone number of the attending physician, authorized nurse practitioner, or authorized physician assistant. If the signature is of an authorized nurse practitioner or authorized physician assistant, the name (signature not required) of the collaborating or supervising physician shall also be included;
- the issuance date and expiration date, if any, of the DNR order; and,
- authorization of EMS personnel to act pursuant to the Comfort Care protocol.
Expiration: To the extent that the underlying DNR order has an expiration date, the CC/DNR Order Verification Form shall have an identical expiration date. This protocol does not prescribe an expiration date, but rather leaves the expiration date up to the physician, authorized nurse practitioner, or authorized physician assistant who issued the underlying DNR order. If the DNR order is revoked by the physician, authorized nurse practitioner, or authorized physician assistant, patient, guardian or authorized health care agent, the CC/DNR Order Verification Form shall be similarly revoked.
Access: The CC/DNR Order Verification form can be accessed by anyone, in downloadable format from the Massachusetts Department of Public Health/Office of Emergency Medical Services website, at www.mass.gov/dph/oems. But it must be fully completed and signed by the attending physician, authorized nurse practitioner or authorized physician assistant, as described above. The CC/DNR protocol is activated when EMS personnel encounter a CC/DNR Order Verification Form (original or copy). EMS personnel must:
- confirm the identity of the individual with the CC/DNR Order Verification Form; and,
- confirm that the CC/DNR Order Verification Form is current and valid.
- If there is a CC/DNR Order Verification Form, and either indicates a revocation or expiration of the CC/DNR Order Verification, EMS personnel shall resuscitate.
Patient Care: Upon confirmation of a current, valid CC/DNR Order Verification Form, EMS personnel shall follow the following procedures:
- If the patient is not in respiratory or cardiac arrest and the patient's heart beat and breathing are adequate, but there is some other emergency illness or injury, the EMS personnel shall provide full treatment and transport, as appropriate, within the scope of their training and level of certification.
- If the patient is in full respiratory or cardiac arrest, the EMS personnel shall not resuscitate, which means:
- do not initiate CPR;
- do not insert an oropharyngeal airway (OPA);
- do not provide ventilatory assistance;
- do not artificially ventilate the patient (mouth-to-mouth, bag valve mask, positive pressure, etc.);
- do not administer chest compressions;
- do not initiate advanced airway measures such as endotracheal intubation;
- do not administer cardiac resuscitation drugs; and,
- do not defibrillate.
- If the patient is not in full respiratory or cardiac arrest, but the patient's heart beat or breathing is inadequate, EMS personnel shall not resuscitate but shall provide, within the scope of their training and level of certification, full palliative care and transport, as appropriate, including:
- emotional support;
- suction airway;
- administer oxygen;
- application of cardiac monitor;
- control bleeding;
- splint;
- position for comfort;
- initiate IV line; and,
- contact Medical Control, if appropriate, for further orders, including necessary medications.
- If EMS personnel have any question regarding the applicability of the CC/DNR Order Verification with regard to any specific individual, the EMS personnel shall:
- verify with the patient, if the patient is able to respond;
- provide full treatment; or,
- contact Medical Control for further orders.
- If efforts are initiated prior to confirmation of the valid CC/DNR Order Verification, discontinue the following resuscitative measures upon verification:
- CPR;
- ventilatory assistance;
- cardiac medications; and,
- advanced airway measures.
Established IV lines and advanced airways should remain in place.
Documentation: When a CC/DNR Order Verification Form is encountered by EMS personnel, it shall be documented. EMS personnel must also document palliative care provided to the patient and that the CC/DNR Order Verification Form is current and valid. Ambulance service personnel must document the presence of the CC/DNR Order Verification on the ambulance trip record.
Revocation: EMS personnel are not to honor any DNR request where the CC/DNR Order Verification Form is void or not intact. If there is a CC/DNR Order Verification Form and it indicates a revocation, EMS personnel shall resuscitate.
- The CC/DNR Order Verification may be revoked by the patient at any time, regardless of mental or physical condition, by the destruction or affirmative revocation of the CC/DNR Order Verification, or by his or her direction that the CC/DNR Order Verification not be followed by out-of-hospital providers or be destroyed. Patients shall be instructed, upon revocation, to destroy the CC/DNR Order Verification Form and the underlying DNR order.
- If an individual identifying him/herself as the health care agent or guardian revokes the CC/DNR Order Verification, EMS personnel shall resuscitate, as this raises an issue of doubt as to the validity of the CC/DNR Order Verification.
- EMS personnel, upon witnessing or verifying a revocation, shall communicate that revocation in writing to the hospital to insure its inclusion in the patient's medical record. Ambulance service personnel shall document the revocation on the ambulance trip record.
- In any situation where EMS personnel have a good faith basis to doubt the continued validity of the CC/DNR Order Verification, EMS personnel shall resuscitate.
Date: original, April 8, 1999; updated, January 22, 2007
This information is provided by the Office of Emergency Medical Services within the Department of Public Health.