This Policy Resource and Education Paper is an explication of the Policy Statement 'Do Not Attempt Resuscitation' (DNAR) in the Out-of-Hospital Setting.

Overview

Emergency medical providers often care for patients in cardiac arrest, and numerous ethical dilemmas may be encountered, including conflicting family opinions, unreasonable requests by bystanders, lack of availability of advance directives, and others.^1,2 Protocols regarding the withholding of resuscitative efforts vary widely among states and EMS jurisdictions within states. Such protocols should address many issues including justification, specificity, patient participation, inclusion of minors, futility, portability, utilization of healthcare resources, and responsibility for pronouncing death.³

As of 2002, 42 states had statewide out-of-hospital DNR protocols.⁴ Of those, 34 were specifically authorized by statute, usually supplemented by regulation or guidelines. Eight states had implemented protocols solely through regulations or guidelines without a change in their legal code. Eight states and the District of Columbia had no statewide protocol in place. Of the 42 protocols, 39 are physician orders requiring physician signature (7 states require only a physician signature, while in 32 states both physician signature and patient endorsement of the DNAR order are required). Three protocols are patient-initiated advance directives and are valid with a witnessed patient signature, no physician involvement required.

The significance of advance directives and their role in health care at the end of life has been previously demonstrated.^5,6,7,8,9 Unfortunately, despite efforts to increase public awareness of advance directives, including public education, education within the medical community, and legal mandates, (such as, the 1991 Federal Patient Self-Determination Act), only a minority of patients have completed advance directives.^10,11,12,13 When available, advance directives can be valuable in ascertaining and following patient wishes for end of life care. Yet, completing standard advance directives do no address resuscitation issues arising in the out-of-hospital setting.

In deference to basic ethical principles, some states and some organizations' suggested statutes have focused on providing comfort care while forgoing only resuscitative interventions. Such documents, (e.g., Comfort Care DNR Order, 'Physician Orders for Life-Sustaining Treatment [POLST], Comfort One®, CPR directive, Arizona's prehospital advance directive statute,¹⁴ and others) emphasize the need for comfort and caring during the dying process.

In both out-of-hospital and hospital settings, current resuscitation techniques generally fail in patients with comorbid illness, terminal cancer, and other irreversible disease states, when they suffer a cardiopulmonary arrest. Public opinion polls echo awareness of these findings, claiming the majority of Americans oppose life support in scenarios of terminal illness or permanent unconsciousness.¹⁵ Despite public and professional agreement regarding the low likelihood of success in such situations, the medicolegal compact to attempt resuscitation, in the absence of a valid DNAR decision, continues to be sanctioned by society and supported by EMS providers as the standard of care. Other exceptions to this custom include when there is irrefutable evidence of death, (e.g., decapitation) or when a decision to withhold resuscitation efforts is made by a licensed physician.

The basic format of Out-of-Hospital DNAR policy should conceptualize the primacy of patient autonomy and respect for persons. Operational protocols must address the practical aspects of implementation. For example, EMS providers should determine whether their patients have valid directives and if so, act in compliance with them.

This document is not intended to establish criteria to determine whether resuscitative efforts should be initiated in individual patients. Such decisions should be made prior to EMS system activation. Unfortunately, family and surrogate discomfort with the home death and dying experience, as well as the lack of timely out patient palliative care planning in the majority of end-of-life situations, continues to place EMS personnel in the difficult position of first response. Therefore, when EMS observes expected signs and symptoms of anticipated death, this needs to be transmitted to nurses and doctors at the hospital interface, to facilitate medical community conversations with patients and families regarding death. Such communication may help reduce 911 calls prior to an expected death in a dying patient. Nor does this document address the type of specific out-of-hospital DNAR document to implement, which reflects prevailing political and professional standards. The following guidelines suggest principles for developing protocols to allow out-of-hospital care providers to withhold CPR.

Guidelines for Developing the Out-of-Hospital DNAR Policy:

To ensure maximum coherence and compliance, a comprehensive out-of-hospital DNAR policy should be endorsed by the widest possible jurisdiction, (local, regional, state), and the medical community, including the EMS governing body. Whenever feasible, legislative support for such a policy should be sought.

The Out-of-hospital DNAR policy should:

1. Note the established fact that current basic and advanced life support interventions may not be appropriate or beneficial in certain clinical settings;
   • Develop a means to educate the public about the appropriate use of 911 following expected deaths.
   • Establish the fact that comfort care and palliative care are affirmative actions for patients with DNAR orders. These appropriate interventions, (e.g., hospice or respite care) DO NOT require EMS activation, and often can be arranged by calling the patient's physician in anticipation of death.
   • Develop a means to educate healthcare workers on topics of Advance Directives, including information on local out-of-hospital DNAR, community hospice alternatives, and bereavement services.
2. Establish consensus on the ideal identification device for DNAR directive to assure continuity of care across settings;
3. Reiterate that initial resuscitative attempts are usually indicated when the patient's wishes are not known;
4. Define the conditions under which an out-of-hospital DNAR order can be considered; including its use in long term care settings and in the emergency department.
5. Define which patients have the decisional capacity to agree to a DNAR order and whether surrogates can sign such orders.
6. Establish a mechanism for determining the precedence of various directives (e.g., Living Will, Durable Power of Attorney for Healthcare, Out-of-Hospital Advance Directive (DNAR).
7. Develop a statutory prioritized list of surrogates to use when there are no advance directives and the patient's decisional capacity is impaired.
8. Consider language acknowledging the growing home hospice movement as concern children and incorporate provisions for document use in minors.
9. Establish that the decision not to attempt resuscitation must be an informed decision made by the patient or surrogate;
10. Identify the information that should be contained in the DNAR order and the authority that will be responsible for developing such a mechanism;
11. Identify the clinical procedures that are to be provided and those withheld in the adherence with the DNAR order, or specify which authority will verify adherence.
12. Define the exact manner in which the DNAR order is to be followed, including the role of on-line medical direction. Each system should ensure that a communication path to access on-line medical direction is immediately available, when necessary.
13. Establish legal immunity provisions for those who implement DNAR orders in good faith.
14. Establish data collection and protocol evaluation to perform periodic operational assessments;
15. Identify permissible exceptions to compliance with DNAR out-of-hospital directives. For example:
    • The patient is able to revoke a written directive at any time.
    • The EMS personnel can cancel the out-of-hospital DNAR order if there are doubts about the document's validity.
    • The EMS personnel can provide CPR if it is necessary for provider safety.
16. Out-of-Hospital DNAR policy should also include a mechanism for ensuring the proper pronouncement of death, for disposition of the decedent's body, and a mechanism for referral for grief counseling. The medical examiner/coroner, police, and EMS providers should be involved in these arrangements.
17. DNAR policy should also include procedures for ensuring that organs or tissues that have been donated by the decedent can be procured appropriately.

References

1. Hall SA: An analysis of dilemmas posed by prehospital DNR orders. J Emerg Med 1997; 15:109-11.
2. Iserson KV: Nonstandard advance directives: a pseudoethical dilemma. J Trauma 1998; 44:139-42.
3. Fitzgerald DJ, Milzman DP, Sulmasy DP: Creating a dignified option: ethical considerations in formulation of prehospital DNR protocol. Am J Emerg Med 1995; 13:223-8.
4. Sabatino CP: Survey of State EMS-DNR Laws and Protocols. Journal of Law, Medicine & Ethics 199;27:297-315.
5. La Puma J, Orentlicher D, Moss RH: Advance directives on admission: clinical implications and analysis of the Patient Self-Determination Act of 1990. JAMA 1991; 266:402-4.
6. Emmanuel L, Barry M, Stoeckle J et al: Advance directives for medical care - a case for greater use. N Engl J Med 1991; 324:889-95.
7. Bedell SE, Pelle D, Maher PL et al: Do-not-resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact? JAMA 1986; 256:344-7.
8. Emanuel EJ: A review of the ethical and legal aspects of terminating medical care. Am J Med 1988; 84:291-301.
9. Emanuel LL: Does the DNR order need life-sustaining intervention: Time for comprehensive advance directives. Am J Med 1989; 86:87-90.
10. Teno J, Lynn J, Wenger N et al: Advance directives for seriously ill hospitalized patients. J Am Geriatr Soc 1997; 45:508-12.
11. The SUPPORT Principle Investigators: A controlled trial to improve care for seriously ill hospitalized patients. JAMA 1995; 274:1591-8.
12. Llovera I, Mandel FS, Ryan JG, Ward MF, Sama A: Are emergency patients thinking about advance directives? Acad Emerg Med 1997; 4:976-80.
13. Broadwell AW, Boisaudin EV, Dunn JK et al: Advance directives in hospital admissions: a survey of patient attitudes. South Med J 1993; 86:165-8.
14. Iserson KV: Prehospital advance directives - A better way. J of Emerg Med 2002; 23:419-20.
15. Marco CA, Schears RM: Societal preferences regarding cardiopulmonary resuscitation. Am J Emerg Med 2002; 20:207-11.

October 2003