Dead or Alive?Dead or Alive?Resuscitation Decisions Resuscitation Decisions

Presence Regional EMSPresence Regional EMS

ObjectivesObjectives

Define the term “advanced directives” as it Define the term “advanced directives” as it applies to EMSapplies to EMS

Discuss the recognition and honoring of a Discuss the recognition and honoring of a Do Not Resuscitate order in the pre-hospital Do Not Resuscitate order in the pre-hospital settingsetting

List the criteria required for field termination List the criteria required for field termination of resuscitationof resuscitation

Discuss the assessments and Discuss the assessments and documentation required for patients meeting documentation required for patients meeting Triple Zero criteriaTriple Zero criteria

Describe situations in which the criteria for Describe situations in which the criteria for Field Death Declaration is applicableField Death Declaration is applicable

Right to Die PeacefullyRight to Die Peacefully

All patients have the right to make decisions All patients have the right to make decisions in advance about the circumstances of their in advance about the circumstances of their death. More and more individuals are death. More and more individuals are making these decisions. EMS Providers making these decisions. EMS Providers must be well aware of patient/family rights in must be well aware of patient/family rights in these difficult situations. these difficult situations.

Protocols and PoliciesProtocols and Policies

Refer to Refer to Region 6 Protocols for:Region 6 Protocols for:

– Do Not Resuscitate Do Not Resuscitate Physician Orders for Life-Sustaining Treatment Physician Orders for Life-Sustaining Treatment

(POLST)(POLST)

– Termination of ResuscitationTermination of Resuscitation– Triple ZeroTriple Zero– Field Death DeclarationField Death Declaration

Advanced DirectivesAdvanced Directives

Legal papers put in place before an Legal papers put in place before an emergency arises outlining individuals who emergency arises outlining individuals who are designated to make medical decisions are designated to make medical decisions for the patient, if the patient is no longer able for the patient, if the patient is no longer able to make decisions.to make decisions.– Durable Power of Attorney for Health CareDurable Power of Attorney for Health Care– Surrogate Decision MakerSurrogate Decision Maker– Living WillLiving Will

Living WillLiving Will

A witnessed written documents voluntarily A witnessed written documents voluntarily executed by a person with the proper executed by a person with the proper formalities instructing the person’s physician formalities instructing the person’s physician to withhold or withdraw death delaying to withhold or withdraw death delaying procedures in the event that the person is procedures in the event that the person is diagnosed as having a terminal event.diagnosed as having a terminal event.

EMS providers will not be held responsible EMS providers will not be held responsible for determining the validity of a Durable for determining the validity of a Durable Power of Attorney, Surrogate Decision Power of Attorney, Surrogate Decision Maker or Living Will.Maker or Living Will.

A Durable Power of Attorney, Surrogate A Durable Power of Attorney, Surrogate Decision Maker or Living Will alone cannot Decision Maker or Living Will alone cannot be accepted as the means to halt be accepted as the means to halt resuscitation by EMS providersresuscitation by EMS providers

If a patient is found in cardiopulmonary If a patient is found in cardiopulmonary arrest and EMS providers are presented arrest and EMS providers are presented with a Durable Power of Attorney, Surrogate with a Durable Power of Attorney, Surrogate Decision Maker or Living Will, CPR must be Decision Maker or Living Will, CPR must be started and Medical Control contacted started and Medical Control contacted immediately for direction. immediately for direction.

Whose orders do you follow?Whose orders do you follow?

EMS providers follow the orders of a EMS providers follow the orders of a physician, not legal paperwork.physician, not legal paperwork.

Medical Control mayMedical Control may

determine that the determine that the

legal paperwork islegal paperwork is

sufficient to halt sufficient to halt

resuscitative measuresresuscitative measures

Do Not ResuscitateDo Not Resuscitate

Do not resuscitate orders ( DNR) orders are Do not resuscitate orders ( DNR) orders are physician orders which advise nursing and physician orders which advise nursing and EMS providers that if a patient suffers a EMS providers that if a patient suffers a cardiopulmonary arrest, the patient does not cardiopulmonary arrest, the patient does not wish to be resuscitated.wish to be resuscitated.

DNRDNR

Because a DNR is an order from a Because a DNR is an order from a physician, a valid DNR can be honored by physician, a valid DNR can be honored by EMS providers.EMS providers.

2013 IDPH Form2013 IDPH Form

To find a copy of the form go toTo find a copy of the form go to– www.idph.state.il.us– Click on A to Z Click on A to Z – Look up Do Not Resuscitate formLook up Do Not Resuscitate form

2013 IDPH Form2013 IDPH Form

Uniform Do-Not Resuscitate Advance Uniform Do-Not Resuscitate Advance DirectiveDirective– Part A Attempt Resuscitation/CPRPart A Attempt Resuscitation/CPR– Yes/NoYes/No– Includes intubation and mechanical ventilationIncludes intubation and mechanical ventilation

Physician Orders for Life Sustaining Physician Orders for Life Sustaining Treatment **Treatment **– Part B If a patient has a pulse and/or is Part B If a patient has a pulse and/or is

breathingbreathing– Comfort measures only Comfort measures only – Limited additional interventionsLimited additional interventions– Intubation and mechanical interventionsIntubation and mechanical interventions

** More later** More later

Part C: Artificially administered nutritionPart C: Artificially administered nutrition– Feeding tube yes/noFeeding tube yes/no

Part D: Documentation of discussionPart D: Documentation of discussion– Signatures of patient, family and witnessSignatures of patient, family and witness

Part E: Signature of attending physicianPart E: Signature of attending physician

A Valid DNRA Valid DNR

A DNR is valid if it is on the appropriate A DNR is valid if it is on the appropriate IDPH formIDPH form– It must be signed by the patient’s physicianIt must be signed by the patient’s physician– It must be signed by the patient or their durable It must be signed by the patient or their durable

power of attorney/surrogate decision maker.power of attorney/surrogate decision maker.

Please notePlease note

– THE DNR DOES NOT HAVE TO BE THE DNR DOES NOT HAVE TO BE RESIGNED WITHIN A PARTICULAR AMOUNT RESIGNED WITHIN A PARTICULAR AMOUNT OF TIME IN ORDER TO REMAIN VALIDOF TIME IN ORDER TO REMAIN VALID

– THE DNR DOES NOT HAVE TO BE ON ANY THE DNR DOES NOT HAVE TO BE ON ANY PARTICULART COLOR OF PAPERPARTICULART COLOR OF PAPER

Revoking a DNRRevoking a DNR

A DNR may be revoked ifA DNR may be revoked if– It is physically destroyed or rescinded by the It is physically destroyed or rescinded by the

physician who wrote the order.physician who wrote the order.– It is physically destroyed or rescinded by the It is physically destroyed or rescinded by the

person who gave consent to the written orderperson who gave consent to the written order

When presented with a DNRWhen presented with a DNR

EMS makes a reasonable attempt to verify EMS makes a reasonable attempt to verify the identity of the patient named in the DNR.the identity of the patient named in the DNR.

If the validity of the DNR is unclear EMS If the validity of the DNR is unclear EMS begins CPR and call Medical Controlbegins CPR and call Medical Control

IF the patient is in cardiopulmonary IF the patient is in cardiopulmonary arrest andarrest and

No valid DNR order is producedNo valid DNR order is produced No agreement by the family on the DNRNo agreement by the family on the DNR Family is very upsetFamily is very upset

EMS providers complete an assessment of EMS providers complete an assessment of the patient begin CPR and call Medical the patient begin CPR and call Medical Control. Control.

DNR does not mean Do Not CareDNR does not mean Do Not Care

Resuscitation ** isResuscitation ** is– CPRCPR– Electrical defibrillationElectrical defibrillation– Tracheal intubationTracheal intubation– Manually assisted ventilationManually assisted ventilation** Part A** Part A

Resuscitation is not **Resuscitation is not **– IV fluidsIV fluids– Dextrose IVDextrose IV These are Physician OrdersThese are Physician Orders– SuctioningSuctioning for life-sustaining treatmentfor life-sustaining treatment– Oxygen administrationOxygen administration** Part B and Part C** Part B and Part C

Whenever a patient with a DNRWhenever a patient with a DNR Suffers cardiopulmonary arrest, EMS calls Suffers cardiopulmonary arrest, EMS calls

Medical Control for direction if:Medical Control for direction if:– The patient is being transported to and from homeThe patient is being transported to and from home– The patient is at a long term care facilityThe patient is at a long term care facility– The patient is on an inter-hospital transferThe patient is on an inter-hospital transfer– The patient is a HospiceThe patient is a Hospice– EMT needs clarification and confirmation of actionsEMT needs clarification and confirmation of actions

All Patients with Valid DNR All Patients with Valid DNR PaperworkPaperwork

Call Medical Control to document incident Call Medical Control to document incident on a recorded line.on a recorded line.

Whenever a patient with a DNRWhenever a patient with a DNR

Is not in cardiac arrestIs not in cardiac arrest Treat appropriately according to applicable Treat appropriately according to applicable

protocolprotocol

Termination of ResuscitationTermination of Resuscitation

Resuscitation may be halted without a Do Not Resuscitation may be halted without a Do Not Resuscitate order if:Resuscitate order if:– Patient is Patient is found in asystolefound in asystole– Unwitnessed arrest with no bystander CPR before Unwitnessed arrest with no bystander CPR before

arrival of EMSarrival of EMS– Patient remains in asystole despite the treatment of the Patient remains in asystole despite the treatment of the

Asystole protocolAsystole protocol CPRCPR Airway securedAirway secured Vascular accessVascular access Epinephrine 1 mgEpinephrine 1 mg

Termination of ResuscitationTermination of Resuscitation

In order to Terminate Resuscitative efforts In order to Terminate Resuscitative efforts for the previous criteriafor the previous criteria– EMS must call Medical Control for permission to EMS must call Medical Control for permission to

terminate resuscitation and put incident on the terminate resuscitation and put incident on the recorded linerecorded line

– The family must be in agreement with the The family must be in agreement with the terminationtermination

– EMS must call the local coronerEMS must call the local coroner

Triple ZeroTriple Zero

A patient who is not viable and for whom A patient who is not viable and for whom resuscitation efforts would be fruitlessresuscitation efforts would be fruitless– UnconsciousUnconscious– No pulseNo pulse– No respirationNo respiration

Triple Zero Signs of Long Term Triple Zero Signs of Long Term DeathDeath

The patient must exhibit one or more of the The patient must exhibit one or more of the following signsfollowing signs– Rigor mortis – Rigor mortis – stiffness of the limbsstiffness of the limbs

– Lividity – Lividity – pooling of blood in dependent parts of the bodypooling of blood in dependent parts of the body

– DecompositionDecomposition– MummificationMummification– DecapitationDecapitation– No resuscitative efforts for at least 20 minutesNo resuscitative efforts for at least 20 minutes– No palpable pulses.No palpable pulses.– Asystole in 3 chest leads (Lead I, II, III)Asystole in 3 chest leads (Lead I, II, III)

Contact Medical Control Contact Medical Control – Document findingsDocument findings– Time Triple Zero confirmedTime Triple Zero confirmed– Physician on the radioPhysician on the radio– On recorded lineOn recorded line

– The confirmation of TripleThe confirmation of Triple

Zero does not constituteZero does not constitute

a pronouncement of death.a pronouncement of death.

RememberRemember

EMS must call the local coronerEMS must call the local coroner Stay with the patient until relieved by Stay with the patient until relieved by

coroner or local law enforcementcoroner or local law enforcement

If any doubt exists, If any doubt exists,

Whether patient meets criteria for Triple ZeroWhether patient meets criteria for Triple Zero

RESUSCITATERESUSCITATE

Especially if:Especially if:

suspected hypothermiasuspected hypothermia

drowning/near drowningdrowning/near drowning

uncertain down timeuncertain down time

EXCEPTIONEXCEPTION

ALL INFANTS WHO ARE ALL INFANTS WHO ARE VICTIMS OF SIDS ARE VICTIMS OF SIDS ARE BROUGHT IN TO THE ED BROUGHT IN TO THE ED WITH RESUSCITATION WITH RESUSCITATION ATTEMPTS!!!ATTEMPTS!!!

Field Death DeclarationField Death Declaration

Chance of survival from traumatic cardiac Chance of survival from traumatic cardiac arrest at the scene is minimalarrest at the scene is minimal

Must make the best use of time, personnel Must make the best use of time, personnel and resourcesand resources

Protocol approved for all levels of EMS Protocol approved for all levels of EMS providers (FR-D, Basic, Intermediate, providers (FR-D, Basic, Intermediate, Paramedic)Paramedic)

Criteria for Field Death Declaration Criteria for Field Death Declaration

> 14 years old> 14 years old Significant mechanism of injurySignificant mechanism of injury Pulseless and not breathing on EMS arrivalPulseless and not breathing on EMS arrival No active electrical activity on the monitorNo active electrical activity on the monitor

or “No Shock Indicated” on AEDor “No Shock Indicated” on AED

Asystole or Idioventricular RhythmAsystole or Idioventricular Rhythm

MAY BE WARM WITHOUT RIGOR OR MAY BE WARM WITHOUT RIGOR OR LIVIDITYLIVIDITY

So what if?So what if?

EMS is called to the scene of a 27 year-old EMS is called to the scene of a 27 year-old male in a motor vehicle crash. The vehicle male in a motor vehicle crash. The vehicle was traveling at a high rate of speed and was traveling at a high rate of speed and rolled over sustaining heavy damage. The rolled over sustaining heavy damage. The patient was ejected and is found face down patient was ejected and is found face down 20 feet from the vehicle. On initial 20 feet from the vehicle. On initial assessment EMS finds the patient pulseless assessment EMS finds the patient pulseless and apneic. and apneic.

How should EMS to proceed?How should EMS to proceed?

PatientPatient

Is an adult ( over the age of 14)Is an adult ( over the age of 14) Trauma resulted in significant mechanism of Trauma resulted in significant mechanism of

injuryinjury Patient was pulseless and not breathing on Patient was pulseless and not breathing on

initial assessmentinitial assessment Major trauma to the body found on Major trauma to the body found on

assessmentassessment

Put patient on the monitor to look for a Put patient on the monitor to look for a viable rhythmviable rhythm

Important PointImportant Point

Medical Control MUST BE Medical Control MUST BE CONTACTED on a CONTACTED on a recorded line for all Field recorded line for all Field Death Declaration Death Declaration questions/decisionsquestions/decisions

RememberRemember

EMS must call the local coronerEMS must call the local coroner Stay with the patient until relieved by Stay with the patient until relieved by

coroner or local law enforcementcoroner or local law enforcement

SummarySummary

Know your policies and protocols regarding Know your policies and protocols regarding end of life/ resuscitation decisions.end of life/ resuscitation decisions.

EMS must always notify Medical Control for EMS must always notify Medical Control for documentation on a recorded line and documentation on a recorded line and guidance.guidance.

EMS must call the coronerEMS must call the coroner

ReviewReview Consider the following questions as a group.Consider the following questions as a group.

– IDPH site code: Use site code assigned to your IDPH site code: Use site code assigned to your agency for 2014.agency for 2014.

If doing this CE individually, please e-mail your If doing this CE individually, please e-mail your answers to:answers to:– Shelley.Peelman@presencehealth.org– Use “Resuscitation Decisions 2014 CE” in subject Use “Resuscitation Decisions 2014 CE” in subject

box.box.– IDPH site code: 06-7100-E-1214WIDPH site code: 06-7100-E-1214W

You will receive an e-mail confirmation. Print You will receive an e-mail confirmation. Print this confirmation for your records and document this confirmation for your records and document in your PREMSS CE record book.in your PREMSS CE record book.

Question 1Question 1

EMS Providers are called to a motor vehicle EMS Providers are called to a motor vehicle crash. The driver of one car is pulseless crash. The driver of one car is pulseless and not breathing. He has massive damage and not breathing. He has massive damage to both lower extremities and a mushy area to both lower extremities and a mushy area on his scalp. He is in asystole on the on his scalp. He is in asystole on the monitor. Does this patient meet Field Death monitor. Does this patient meet Field Death Declaration criteria?Declaration criteria?

Question 2Question 2

EMTs have been called to the house by neighbors EMTs have been called to the house by neighbors concerned that they have not seen Floyd all day. concerned that they have not seen Floyd all day. Floyd usually takes his dog out for walks at least Floyd usually takes his dog out for walks at least twice a day, but no one has seen him since twice a day, but no one has seen him since yesterday. Police find Floyd in his recliner, yesterday. Police find Floyd in his recliner, pulseless and not breathing. He has purple pulseless and not breathing. He has purple discoloration of his dependent parts and is very discoloration of his dependent parts and is very stiff. The monitor shows asystole in all leads. stiff. The monitor shows asystole in all leads. Does Floyd meet Triple Zero criteria?Does Floyd meet Triple Zero criteria?

Question 3Question 3

Mary Jane’s mother has cardiac arrested. Mary Jane’s mother has cardiac arrested. Mary Jane thinks her mom has a living will, Mary Jane thinks her mom has a living will, but she can’t find it. She has never heard of but she can’t find it. She has never heard of a durable power of attorney. What should a durable power of attorney. What should EMS do? EMS do?

Question 4Question 4

Susan is lying in her back yard. It is early Susan is lying in her back yard. It is early April, railing and about 50 degrees out. She April, railing and about 50 degrees out. She is not moving, stiff and cold to touch. EMS is not moving, stiff and cold to touch. EMS cannot find any pulses on her and she does cannot find any pulses on her and she does not appear to be breathing. Does she meet not appear to be breathing. Does she meet criteria for Triple Zero? Why or why not?criteria for Triple Zero? Why or why not?

Question 5Question 5

Mr. Blue has a signed Do Not Resuscitate Mr. Blue has a signed Do Not Resuscitate order for his mother who is 90 years old with order for his mother who is 90 years old with cancer. Now that she is pulseless and not cancer. Now that she is pulseless and not breathing he has changed his mind and breathing he has changed his mind and wants everything done. What should EMS wants everything done. What should EMS Providers do?Providers do?

Question 6Question 6

Mrs. Green is dying of cancer. She has a Mrs. Green is dying of cancer. She has a DNR. Mrs. Green has suffered a cardiac DNR. Mrs. Green has suffered a cardiac arrest and the local fire department has arrest and the local fire department has started CPR. As a transport paramedic started CPR. As a transport paramedic agency what should you do now?agency what should you do now?

Question 7Question 7

Mike’s father is in cardiac arrest. Mike says Mike’s father is in cardiac arrest. Mike says he has durable power of attorney, but he he has durable power of attorney, but he can’t prove it with paperwork. He says his can’t prove it with paperwork. He says his father is a DNR but he has no written order. father is a DNR but he has no written order. He wants CPR stopped. What should EMS He wants CPR stopped. What should EMS providers do?providers do?

Question 8Question 8

Mrs. Smith has suffered a cardiac arrest. Mrs. Smith has suffered a cardiac arrest. Responding EMS Providers have started Responding EMS Providers have started CPR. She is entubated, given epinephrine CPR. She is entubated, given epinephrine and remains in asystole. CPR continues, and remains in asystole. CPR continues, she is given additional epinephrine. The she is given additional epinephrine. The family is crying “please let her go”. What family is crying “please let her go”. What should EMS do? should EMS do?

Question 9Question 9

It is snowing and the EMS transport unit can only go It is snowing and the EMS transport unit can only go about 20 miles an hour on the highway. On board about 20 miles an hour on the highway. On board they have a 6- year-old boy who was hit by a car in a they have a 6- year-old boy who was hit by a car in a rural community. The child is critical and had a rural community. The child is critical and had a pulse at the scene but about 10 minutes ago he went pulse at the scene but about 10 minutes ago he went into cardiac arrest. EMS has done CPR, intubated into cardiac arrest. EMS has done CPR, intubated him, and started IV fluids. They have given him, and started IV fluids. They have given Epinephrine according to protocol. He is asystole Epinephrine according to protocol. He is asystole and EMS is still 8 miles from the hospital. Does this and EMS is still 8 miles from the hospital. Does this child meet Field Death Declaration? Why or Why child meet Field Death Declaration? Why or Why not?not?

Question 10Question 10

Eric’s mom is in the Hospice program for Eric’s mom is in the Hospice program for emphysema. She has a valid DNR signed emphysema. She has a valid DNR signed by her, her doctor and Eric. Eric’s mom is in by her, her doctor and Eric. Eric’s mom is in cardiac arrest. Eric wants to honor the DNR cardiac arrest. Eric wants to honor the DNR but his sister just got here from Florida and but his sister just got here from Florida and she is screaming “save my mother!!”. What she is screaming “save my mother!!”. What should EMS do?should EMS do?

AnswersAnswers

1.1. YesYes

2.2. YesYes

3.3. Begin resuscitation (CPR) and call Medical Control for Begin resuscitation (CPR) and call Medical Control for guidanceguidance

4.4. She does not meet criteria because of hypothermia, “ you She does not meet criteria because of hypothermia, “ you aren’t dead until you are warm and dead”.aren’t dead until you are warm and dead”.

5.5. Begin resuscitation (CPR) and call Medical Control for Begin resuscitation (CPR) and call Medical Control for guidanceguidance

6.6. Begin resuscitation (CPR) and call Medical Control for Begin resuscitation (CPR) and call Medical Control for guidance regarding permission to halt resuscitationguidance regarding permission to halt resuscitation

7.7. Continue resuscitation (CPR) and call Medical Control for Continue resuscitation (CPR) and call Medical Control for guidance.guidance.

8.8. Continue resuscitation (CPR) and call Medical Control for Continue resuscitation (CPR) and call Medical Control for guidance regarding permission to halt resuscitationguidance regarding permission to halt resuscitation

9.9. No, the patient is a child (under age 14) and was not No, the patient is a child (under age 14) and was not found pulseless and not breathing.found pulseless and not breathing.

10.10. Begin resuscitation (CPR) and call Medical Control for Begin resuscitation (CPR) and call Medical Control for guidance.guidance.