Development of a county pre-hospital DNR program: Contributions of a bioethics network

Abstract

OverviewDo-not-resuscitate (DNR) orders are written by physicians so that cardiopulmonary resuscitation (CPR) is not administered to patients who do not want to be resuscitated should they have a cardiac or pulmonary arrest. DNR orders are appropriate, effective, and common in hospitals: it is difficult to understand why they have largely been excluded from pre-hospital settings (1)(2)(3)(4). It is also surprising how little effort has been expended to make DNR orders portable between settings and durable in time. We will discuss the development of a pre-hospital DNR program in Orange County, California, with primary emphasis on the supportive role played by the Orange County Bioethics Network (OCBEN).Emergency room physicians and nurses as well as emergency medical technicians and paramedics have long been concerned about the occasional resuscitated patient for whom resuscitation seemed inappropriate, most particularly when the patient's surrogate, or the patient him/herself subsequently said that he/she would not have wanted resuscitation. These are the exceptions that prove the rule that under emergency circumstances the presumption should be in favor of life-sustaining or life-restoring treatment.To address some of these exceptions, emergency room personnel, the Program Director of the

A Method to Communicate Patient Preferences About Medically Indicated Life‐Sustaining Treatment in the Out‐of‐Hospital Setting

“…Despite the emerging need for portable DNR orders and directives to health care providers, few communities have developed a system to communicate these orders 5–10 . As recently as 1988, only eight states had specific statewide policies enabling prehospital DNR orders, and five states specifically mandate cardiopulmonary resuscitation in all cases of out‐of‐hospital arrest 16 .…”

“…To help honor patient preferences across treatment settings, some physicians advocate portable DNR orders and directives to healthcare providers 3,4 . However, few communities have developed a system to communicate these orders 5–10 . Recent reports also suggest that even patients who have completed advance directives that are the basis for physician orders rarely have them available when they arrive in an emergency department 11–13 .…”