Do-not-resuscitate orders. Where are they in the prehospital setting?

The evolution of health care advance planning law and policy

CONTEXT

The legal tools of health care advance planning have substantially changed since their emergence in the mid-1970s. Thirty years of policy development, primarily at the state legislative level addressing surrogate decision making and advance directives, have resulted in a disjointed policy landscape, yet with important points of convergence evolving over time. An understanding of the evolution of advance care planning policy has important implications for policy at both the state and federal levels.

METHODS

This article is a longitudinal statutory and literature review of health care advance planning from its origins to the present.

FINDINGS

While considerable variability across the states still remains, changes in law and policy over time suggest a gradual paradigm shift from what is described as a "legal transactional approach" to a "communications approach," the most recent extension of which is the emergence of Physician Orders for Life-Sustaining Treatment, or POLST. The communications approach helps translate patients' goals into visible and portable medical orders.

CONCLUSIONS

States are likely to continue gradually moving away from a legal transactional mode of advance planning toward a communications model, albeit with challenges to authentic and reliable communication that accurately translates patients' wishes into the care they receive. In the meantime, the states and their health care institutions will continue to serve as the primary laboratory for advance care planning policy and practice.

Implementation of a novel prehospital advance directive protocol in southeastern Ontario

INTRODUCTION

Do not resuscitate (DNR) orders are commonly accepted in most health care settings, but are less widely recognized in the prehospital setting. We describe the implementation of and satisfaction with a prehospital DNR protocol that allows paramedics to honour verbal and non-standard written DNR requests.

METHODS

This prospective observational study reviewed all cardiac arrests in southeastern Ontario between March 1, 2003 and September 31, 2005. Following a verbal or non-standard written DNR request, paramedics completed a questionnaire and a follow-up structured telephone interview was conducted with surrogate decision makers (SDMs).

RESULTS

There were 1890 cardiac arrests during the study period, of which 86 met our inclusion criteria. Paramedic surveys were available for 82 cases (95%), and surrogate decision makers (SDMs) were successfully contacted in 50 (58%) of them. Two SDMs declined to be interviewed. The mean patient age was 72.7 (standard deviation 13.8) years and 65% were male. Sixty-three (73%) of DNR requests were verbal, and 23 (27%) were written. The mean paramedic comfort was rated 4.9 on a 5-point Likert scale (with 5 being "very comfortable") (95% confidence interval [CI] 4.9-5.0). The mean SDM comfort was rated by paramedics as 4.9 (95% CI 4.8-4.9). SDMs reported comfort in withholding CPR in 47 of 48 cases (98%), and with paramedic care in all cases. One SDM stated that although it was consistent with the patient's wishes, she was uncomfortable having to make the DNR request.

CONCLUSIONS

Satisfaction with this novel prehospital DNR protocol was uniformly high among paramedic and SDM respondents. It appears that such a protocol is feasible and acceptable for the prehospital setting. Our conclusions are limited by a small sample size, the lack of a comparison group, and limited follow-up.

Development of a statewide protocol for the prehospital identification of DNR patients in Connecticut including new DNR regulations

This article describes the development and implementation of a standardized protocol for the prehospital identification of terminally ill "do-not-resuscitate" (DNR) patients. This pilot program was initiated by members of the Connecticut College of Emergency Physicians and instituted on a voluntary basis statewide in July 1991. Key components of the program are discussed, including developmental rationale, formation of a DNR Coalition, educational rollout, and implementation activities. The second phase of this initiative involved passage of state legislation and development of new DNR regulations, which went into effect in July 1997. The regulations successfully addressed the limitations and difficulties encountered in the pilot program. Major modifications included applicability of the bracelet program to a broader group of DNR patients, development of a uniform system for interfacility transfer of DNR patients, and mandatory compliance by health care personnel.

Physicians' experiences with prehospital do-not-resuscitate orders in North Carolina

INTRODUCTION

Many states are implementing prehospital do-not-resuscitate (DNR) programs through legislation or by state or local protocol. There are no outcome studies in the literature regarding the utilization of, access to, or barriers to prehospital DNR programs, nor are there studies that evaluated whether they meet the patients' needs.

STUDY OBJECTIVE

To explore physicians' perceptions of the utilization of, access to, and barriers to a southeastern state's prehospital DNR program, and to identify key professional groups needing information about prehospital DNR issues.

METHODS

A convenience sample survey and a descriptive review using retrospective, self-report questionnaires sent to all physicians who requested and obtained a supply of the state's out-of-facility DNR forms in 1993.

RESULTS

Respondents reported that the most common terminal conditions for patients with prehospital DNR orders are cancer and multiple chronic diseases in elderly patients. More than half of the physicians recalled that enrolled patients had engaged the services of emergency medical services (EMS), most often because the patients' conditions worsened, and the families were uncertain about what to do. Most of the enrolled patients have at least one other DNR order in another health-care setting, and are at home with hospice care or home-health care at the time of the prehospital DNR order implementation. The most frequent barrier to honoring dying patients' wishes in the prehospital environment is a lack of knowledge of prehospital issues by patients, families, primary care physicians, and nursing home staff. Ninety-eight percent of the respondents support a single, universal DNR order that would apply across all health-care settings.

CONCLUSIONS

Patients, families, and key health-care professional groups need to be targeted with educational programs regarding prehospital DNR issues. Primary care physicians, using the current prehospital DNR program, support more comprehensive approaches to DNR orders across health-care settings.