Comfort Care/Do Not Resuscitate Order Verification Protocol

INTRODUCTION

Emergency medical services (EMS) personnel (refers collectively to Emergency Medical Technicians - EMTs and First Responders) are required to provide emergency care and to transport a patient to an appropriate medical facility. EMS personnel are further required to provide treatment to the fullest extent possible, subject to their level of training. However, more and more patients, where it is medically appropriate, are opting not to be resuscitated. Many have even arranged with their physician, nurse practitioner or physician assistant for a Do Not Resuscitate (DNR) order; an advance directive indicating their desire not to be resuscitated.  However, since there was previously no uniform mechanism to enable EMS personnel to recognize DNR orders in out-of-hospital settings, EMS personnel were obligated to perform full resuscitative measures, subject only to specific medical direction from Medical Control, when encountering a patient unable to convey directions regarding medical treatment.

While it is clear within the emergency medical services' community that a competent patient has the authority to determine his/her medical treatment, EMS personnel have been unable to consider a terminally ill patient's wishes regarding resuscitation in the pre-hospital setting where the patient is either not conscious or not competent, due to the difficulty of ascertaining the validity of these wishes in the field under emergency conditions. Usually there is no ongoing relationship between the emergency medical services personnel and the patient. Emergency conditions require an immediate response and accurate identification. Authentication of individuals and documents is difficult, if not impossible, under emergency field conditions.

This Comfort Care / DNR ("CC/DNR") Order verification Protocol is designed to allow EMS personnel to honor a DNR order in an out-of-hospital setting. To date, there are no standardized documents by which EMS personnel can verify a DNR order in the field, under emergency conditions. This protocol provides for a state-wide, uniform pre-hospital DNR order verification, approved by the Department of Public Health (DPH), that EMS personnel can instantly recognize as an acceptable pre-hospital DNR order; thus, allowing EMS personnel to honor the patient's request for no resuscitation and to provide the patient with only palliative in conformance with the Comfort Care protocol.

PURPOSE

The purpose of this protocol is to: (1) provide a verification/authetication of DNR orders to enable EMS personnel to honor DNR orders in out-of-hospital settings; (2) clarify the role and responsibilities of EMS personnel at the scene and/or during transport of patients who have a current, valid CC/DNR Order Verification; (3) avoid resuscitation of patients who have a current, valid pre-hospital DNR order; and (4) provide palliative/comfort care measures for patients with a current, valid CC/DNR Order Verification.  This protocol is not intended to alter the standard of practice in issuing DNR orders in any way, but to provide a standardized mechanism for the verification of the DNR order so that it may be recognized in out-of-hospital settings..

DEFINITIONS

1. Attending Physician: A physician, licensed pursuant to M.G.L. c.112 § 2, selected by or assigned to a patient, who has primary responsibility for the treatment and care of the patient, in whatever setting medical diagnosis or treatment is rendered. Where more than one physician shares such responsibility, any such physician may act as the attending physician for the purposes of this protocol.
2. Authorized Nurse Practitioner ("Authorized NP"):  A registered nurse in the Commonwealth with advanced nursing knowledge and clinical skills as required by M.G.L. c. 112, § 80B and 244 CMR 4.00 et seq.  A nurse practitioner may write a DNR order, where this activity is agreed upon by the nurse practitioner and the collaborating physician in written practice guidelines (244 MCR 4.22 (1)).  I is the obligation of the nurse practitioner, the collaborating physician, and the institution where the nurse practitioner is practicing at the time the CC/DNR is issued to ensure that the nurse practitioner is authorized under his/her written practice guidelines to write a DNR Order and by extension to sign the Comfort Care Verification form.
3. Authorized Physician Assistant ("Authorized PA"):  A person who meets the requirements for registration set forth in M.G.L. c. 112, § 9I, and who may provide medical services appropriate to his or her training, experience and skill under the supervision of a registered physician.  The Board of Registration provides that a physician assistant may write DNR orders if: (1) his /her supervising physician determines that issuing a DNR order is within the competence of the physician assistant given the physician assistant's level of training and expertise (263 CMR 5.04 (1)), and (2) with regard to initial DNR orders, the physician assistant must consult with his/her supervising physician prior to issuance.  A physician assistant may properly review and renew a preexisting DNR order without prior consultation with his/her supervising physician.  Since the COmfort Care/Do Not Resuscitate Order Verification is a verification of existing valid DNR order, the signing of the verification is comparable to the renewal of a preexisting DNR order.  It is the obligation of the physician assistant,  his/her supervising physician, and the institution where the physician assistant is practicing at the time the CC/DNR is issued to ensure that the physician assistant is authorized under his/her practice guidelines to write a DNR order and by extension to sign the Comfort Care Verification form.
4. Cardiopulmonary Resuscitation ("CPR"): shall include for the purposes of this protocol, cardiac compression, artificial ventilation, oropharyngeal airway (OPA) insertion, advanced airway management such as endotracheal intubation, defibrillation and related procedures.
5. Comfort Care /DNR Order Verification Bracelet ("bracelet"): A bracelet modeled after a hospital identification bracelet, which shall include the patient's name, date of birth, gender, date of expiration of underlying DNR order, if there is one, and the signature and telephone number of an attending physician. The bracelet can only be issued to someone who has a valid CC/DNR Order Verification Form and must be issued by an attending physician. Wearing the bracelet is voluntary; however, it is strongly recommended for individuals who remain mobile.
6. Comfort Care / DNR Order Verification Form ("form"): A standard state-wide form for verification of DNR orders in the out-of-hospital setting, approved by the Department of Public Health. The CC/DNR Order Verification Form shall include the patient's name, date of birth, gender, date of expiration of underlying DNR order, if there is one, and the signature and telephone number of an attending physician. The CC/DNR Order Verification Form is the only DNR document that EMS personnel will be instructed to honor and can only be issued by an attending physician, authorized nurse practitioner, or authorized physician assistant.
7. Comfort Care / DNR Order Verification Protocol: A standardized state-wide patient care protocol to be followed by EMS personnel (EMTs and First Responders) when encountering a patient with a current, valid, CC/DNR Order Verification Form and/or Bracelet. The protocol provides that the patient in respiratory or cardiac distress will receive palliative comfort care consistent with the scope of the EMTs training and certification, but no resuscitative measures. The protocol applies to all emergency medical services personnel (Basic, Intermediate, and Paramedic EMTs, and First Responders) operating in an out-of-hospital setting and requires that they perform patient assessment and treatment in accordance with this protocol.
8. Emergency Medical Services Personnel: Any EMT certified pursuant to 105 CMR 170.000 et seq. and any First Responder as defined in 105 CMR 171.050.
9. Guardian: An individual appointed by the court, pursuant to M.G.L. c. 201 § 6, 6A, or 6B, to make decisions for a person who is mentally ill, mentally retarded or unable to make or communicate informed decisions due to physical incapacity or illness, provided that the appointment as guardian includes the right to make health care decisions; or, a parent or other individual who is legally entitled to make decisions about the care and management of a child during his/her minority.
10. Health Care Agent: An individual authorized by a health care proxy to make health care decisions on behalf of the principal, pursuant to M.G.L. c. 201D. The authority of the health care agent becomes effective only upon a written determination of the attending physician, pursuant to M.G.L. c. 201D sec. 6, that the principal lacks the capacity to make or to communicate health care decisions.
11. Life-sustaining procedure: Cardiopulmonary resuscitation (as defined in number 4 above). Life-sustaining procedures shall not include any medical procedure or intervention considered necessary by the attending physician or EMS personnel to provide comfort care or to alleviate pain.
12. Medical Control Physician: A physician designated within the EMS system to provide on-line and off-line medical direction to EMS personnel.
13. Palliative care: Care that eases or relieves symptoms without correcting the underlying cause or disease.
14. Out-of-hospital: Any setting outside a hospital where EMS personnel may be called and may encounter patients with CC/DNR Order Verifications including, but not limited to, long-term care, hospice, assisted living, private homes, schools, inter-facility transport, and other public areas.

It is well settled in Massachusetts that individuals, while competent, have the right to determine the course of their medical treatment, including the right to refuse medical treatment and to make end of life decisions in advance. Norwood Hospital v. Munoz. 409 Mass. 116, 564 N.E.2d 1017 (1991); Brophy v. New England Sinai Hospital, 398 Mass. 417, 497 N.E.2d 626 (1986), Lane v. Candura, 6 Mass. App. Ct. 377, 376 N.E.2d 1232 (1978); and Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977). Similarly, it is recognized that incompetent individuals have the same right to determine the course of their medical treatment as well as to refuse medical treatment. Brophy v. New England Sinai Hospital, supra; Saikewicz, supra, Matter of Spring, 380 Mass. 629, 405 N.E.2d 115 (1980). See also Matter of Dinnerstein, 6 Mass. App. Ct. 466, 380 N.E.2d 134 (1978); and Care and Protection of Beth, 412 Mass. 188, 587 N.E.2d 1377 (1992).

As an extension of the health profession into the field, the emergency medical system has the same obligation to recognize an individual's right to refuse medical treatment in a pre-hospital setting, where the competency of the individual or the authenticity of the documentation can be validated.

Further authority: M.G.L. c. 111C and 105 CMR 170.000 et seq.; M.G.L c. 111C § 201 and 105 CMR 171.000 et seq.
 

IMPLEMENTATION PROCEDURES

ELIGIBILITY: Anyone with a current, valid DNR order is eligible for a CC/DNR Order Verification (Form and/or Bracelet), including minors.

A DNR order is an order, executed by a physician, issued according to the current standard of care. The standard for issuing the DNR order is neither defined nor changed by this protocol. This protocol simply serves to verify, for EMS personnel, a DNR Order issued by a physician.

VALIDITY: To assure that a DNR order is recognized in any out-of-hospital setting, an attending physician, authorized nurse practitioner, or authorized physician assistant must provide a patient, who has a current DNR order, with a fully executed CC/DNR Order Verification. Pursuant to this protocol, EMS personnel will be instructed to honor a current valid CC/DNR Order Verification Form od CC/DNR Order Verification Bracelet. Patients without CC/DNR Order Verification Form or Bracelet will be resuscitated by EMS personnel in accordance with standard EMS protocols.

CONTENT: The CC/DNR Order Verification Form shall include:

• the name, date of birth, gender, and address of the patient;
• the name of the guardian or health care agent, if any;
• the signature of the patient or of the guardian or health care agent;
• verification by the attending physician, authorized nurse practitioner, or authorized physician assistant of the existence of a current valid DNR order;
• the signature and telephone number of the attending physician, authorized nurse practitioner, or authorized physician assistant.  If the signature is on an authorized nurse practitioner or authorized physician assistant, the name (signature not required) of the collaborating or supervising physician shall also be included;;
• the issuance date and expiration date of the DNR order, if any; and,
• authorization of EMS personnel to act pursuant to the Comfort Care protocol.

• the name, date of birth, gender, and address of the patient;
• the expiration date of the DNR order, if any;
• the printed name, signature and telephone number of the attending physician, authorized nurse practitioner, or authorized physician assistant.  If the signature is of an authorized nurse practitioner or authorized physician assistant, the name (signature not required) of the collaborating or supervision physician shall also be included..

ACCESS: This protocol is implemented solely through physicians. Only an attending physician can execute the CC/DNR Order Verification Form and provide the CC/DNR Order Verification Bracelet, if the bracelet is requested. This protocol is activated when EMS personnel encounter a CC/DNR Order Verification Form or Bracelet. EMS personnel must:

• confirm the identity of the individual with the CC/DNR Order Verification Form or Bracelet; and,
• confirm that the CC/DNR Order verification Form is an original and is current and valid, or that the patient is wearing a current and valid CC/DNR Order Verification Bracelet.

PATIENT CARE: Upon confirmation of a current, valid, CC/DNR Order Verification Form or Bracelet, EMS personnel shall follow the following procedures:

• If the patient is not in respiratory or cardiac arrest and the patient's heart beat and breathing are adequate, but there is some other emergency illness or injury, the EMS personnel shall provide full treatment, within the scope of their training and level of certification.

• If the patient is in full respiratory or cardiac arrest, the EMS personnel shall not resuscitate, which means:
1. do not initiate CPR;
2. do not insert an oropharyngeal airway (OPA);
3. do not provide ventilatory assistance;
4. do not artificially ventilate the patient (mouth-to-mouth, bag valve mask, positive pressure, etc.);
5. do not administer chest compressions;
6. do not administer advanced airway measures such as endotracheal intubation;
7. do not administer cardiac resuscitation drugs; and,
8. do not defibrillate.

• If the patient is not in full respiratory or cardiac arrest, but the patient's heart beat or breathing is inadequate, EMS personnel shall not resuscitate but shall provide, within the scope of their training and level of certification, full palliative care, as appropriate, including:
1. emotional support;
2. suction airway;
3. administer oxygen;
4. application of cardiac monitor;
5. control bleeding;
6. splint;
7. position for comfort;
8. initiate IV line; and,
9. contact Medical Control, if appropriate, for further orders, including necessary medications.

• If EMS personnel have any question regarding the applicability of the CC/DNR Order Verification with regard to any specific individual, the EMS personnel shall:
1. verify with the patient, if the patient is able to respond;
2. provide full treatment; or,
3. contact Medical Control for further orders.

• If efforts are initiated prior to confirmation of the valid CC/DNR Order Verification, discontinue the following resuscitative measures upon verification:
1. CPR;
2. ventilatory assistance
3. cardiac medications; and,
4. advanced airway measures.


Established IV lines and advanced airways should remain in place.

REVOCATION: EMS personnel are not to honor any DNR request where the CC/DNR Order Verification Form or Bracelet, if present, is voided or not intact. If there is a CC/DNR Order Verification Form and Bracelet, and either indicates a revocation, EMS personnel shall resuscitate.

• The CC/DNR Order Verification may be revoked by the patient at any time, regardless of mental or physical condition, by the destruction or affirmative revocation of the CC/DNR Order Verification, or by his or her direction that the CC/DNR Order Verification not be followed by out-of-hospital providers or be destroyed.  Patients shall be instructed, upon revocation, to destroy the CC/DNR Order Verification Form, CC/DNR Order Verification Bracelet, if issued, and the underlying DNR order.

• If an individual identifying him/herself as the health care agent or guardian revokes the CC/DNR Order Verification, EMS personnel shall resuscitate, as this raises an issue of doubt as to the validity of the CC/DNR Order Verification.

• EMS personnel, upon witnessing or verifying a revocation, shall communicate that revocation in writing to the hospital to insure its inclusion in the patient's medical record. Ambulance service personnel shall document the revocation on the ambulance trip record.

• In any situation where EMS personnel have a good faith basis to doubt the continued validity of the CC/DNR Order Verification, EMS personnel shall resuscitate.

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