STAFFORD COUNTY FIRE AND EMERGENCY MEDICAL SERVICES STANDARD OPERATING PROCEDURE SUBJECT: APPROVED: Director of Fire, Rescue & Emergency Services APPROVED: Fire and EMS Commission, Chairman APPROVED: Stafford County Operational Medical Director SOP # Fire/EMS03-0034 INITIATED April 2, 2003 REVISED Durable Do Not Resuscitate Order A. PURPOSE: To establish the policy to be used by Stafford County Fire and Rescue Personnel in the determination and management of the deceased. B. POLICY: The decision to withhold resuscitative efforts is difficult at all times and should never be taken lightly. The first responding personnel who are certified at a minimum of EMT-B shall make the determination that resuscitation should not be employed. C. INDICATIONS: Patients having a valid Virginia (VA) Durable Do Not Resuscitate (DDNR) Order, Alternate Form of DDNR Identification, or other DNR orders issued in a hospital or other health care facility who experience: 1. Respiratory arrest 2. Cardiac arrest D. CONTRAINDICATIONS: The DDNR is contraindicated in the following circumstances: 1. Orders deemed not valid 2. Orders that have been revoked 3. Patients not experiencing respiratory or cardiac arrest E. DEFINITIONS: 1. Virginia Durable DNR Order (DDNR) – A written physician’s order in a form approved by the Board of Health. This form authorizes qualified EMS personnel to withhold or withdraw cardiopulmonary resuscitation from a particular patient experiencing respiratory or cardiac arrest, regardless of the patient’s setting (home, hospital, or other health care facility). DDNR orders shall not authorize the withholding of other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or to alleviate pain. Valid EMS DNR Orders are considered Durable DNR Orders and do not expire if issued on or after July 02, 1998. 2. Alternate Form of DDNR Identification (Bracelets/Necklaces) – In conjunction with the issuance of Durable DNR Orders, the Board of Health has authorized an approved bracelet or necklace as an alternate form of Durable DNR Order Identification. Any such alternate form may be utilized to validate or used in place of an original DDNR order. It must contain the following information: Patient’s full legal name, DDNR number on the DDNR form or unique number assigned to the patient by the vendor, the words “Virginia Do Not Resuscitate”, vendors 24-hour phone number and physician’s name and phone number. 3. Other DNR Order Forms – Any DNR order not issued on the DDNR Order Form. These orders must be written or verbally given by a physician, who has a bona fide physician/patient relationship, direction the patient not be resuscitated. The order must include the patient’s full legal name, the physician’s signature and the date issued. Examples include: a. DNR order written for a patient in a hospital or other health care facility in accordance with accepted medical practice. To be honoured by EMS personnel such other DNR orders must contain a do not resuscitate determination, physicians signature, date of issue and patients signature, of if applicable, the person authorized to consent on the patients behalf. If the patient experiences cardiac or respiratory arrest during transport to another facility, EMS personnel must document in writing on the PPCR that they received a doctor’s verbal order or were shown a valid DNR order. b. Direct verbal orders given by a physician who is physically present in attendance of a patient in cardiac or respiratory arrest. 4. Health Care Facility – Any institution, place, building or agency required to be licensed under Virginia law, including, but not limited to, any hospital, nursing facility or nursing home, adult care residence, assisted living facility, or ambulatory surgical center. F. PROCEDURE: 1. Perform routine patient assessment and resuscitation or intervention until valid DDNR is confirmed. 2. Locate original DDNR order form: a. Private Residential Settings (must be VA’s DDNR form): 1) 2) 3) 4) 5) Patient’s bedroom door At the patient’s bedside On the refrigerator In the patient’s wallet On the patient (EMS DNR bracelet or necklace) b. Health Care Facility Settings (may use VA’s DDNR form or other DNR orders): 1) Patient’s living areas – same locations as identified above. 2) Admitted patients: a) May be presented by facility staff on the VA DDNR form or other specific form used for DNR orders. b) May be a direct order by a physician physically present in attendance of the patient at the time of death. c. Assure DDNR order is valid and has not been revoked 1) Valid forms must be intact and not defaced and VA DDNR forms must be issued on or after July 02, 1998. a) b) c) d) e) Must see the original intact form (or approved alternate identification on the patient): Virginia DDNR Form. Alternate Form of DDNR identification Other DNR Order (healthcare facility only) On scene physician – direct orders from a physician physically present in attendance of the patient at the time of death, may be followed. 2) Revocation – The following people may revoke a DDNR order: a) The patient by destroying the Virginia DDNR form or the EMS DNR order or by verbally withdrawing consent to the order. b) The person authorized to consent on the patient’s behalf. c) A physician who is physically present at the patient’s side. 3. Make a good faith effort to verify the patient’s identity and assure patient’s identity matches that on the DDNR order form. Verification may be confirmed by photo identification or come from those present on the scene (i.e., patient’s family, friends, or health care providers). 4. Patients in respiratory or cardiac arrest – withhold or withdraw the following treatments: a. b. c. d. e. Artificial ventilation CPR Defibrillation Endotracheal intubation or Combitube utilization Cardiac resuscitation medications 5. Appropriately treat patients who are not in cardiac arrest: a. b. c. d. e. f. g. h. Airway open (no ventilation, Combitube or endotracheal intubation) Suction Oxygen Control of bleeding Make patient comfortable (i.e., patient positioning) and be supportive IV fluids and/or pain medication by protocol (ALS only) Contact On-Line Medical Control if questions or concerns arise Assure that the DDNR order accompanies the patient if transported 6. If patient has expired: a. Notify the police department through Communications b. Complete the pre-hospital patient care report form and note: 1) What type of DNR order was utilized (i.e., VA DDNR form, DNR bracelet or necklace, direct order from physician or other DNR order) 2) DDNR order number 3) Patient’s attending physician c. Comfort family members and be supportive d. Preserve the scene and await arrival of law enforcement 7. Special considerations: a. If the family becomes confrontational, insisting on resuscitation and demanding attempts regardless of a valid DDNR order, begin CPR if needed and move the patient to the ambulance for transport. Contact Medical Control for further instructions. b. In cases where no valid DDNR order exists and CPR and resuscitation are indicated, resuscitate patient according to protocol. If the family becomes confrontational, demanding resuscitation be stopped, call for law enforcement. If the family physician interferes with resuscitation or threatens physical harm, stop the resuscitation. Seek a safe environment and await law enforcement. Virginia Code section 54.1 – 2987.1 is attached as incorporated by reference. Referenced from: Emergency Regulations Governing the Durable Do Not Resuscitate Program, Virginia Department of Health, March 27, 2002.