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Utah EMS/DNR Implementation Protocol for Health Care Providers
Introduction
To be eligible for the EMS/DNR Directive, a declarant must be 18 years of age
and suffering from a terminal condition as determined by their physician. If
the patient meets this criteria and desires that no cardiopulmonary resuscitation
be done should they arrest, their physician will give them documentation and
a bracelet to identify them as an EMS/DNR declarant. This modification to the
State of Utah Living Will Act does not eliminate the Living Will, Special Power
of Attorney or the medical Treatment Plan options. It simply provides a quick
and easy recognition of declarants for Emergency Medical Technicians and Paramedics
who respond to help these patients. The EMS personnel need only see the Directive
or the bracelet and confirm the identity of the patient to concur with their
wishes of no resuscitation.
For more information contact:
The Bureau of Emergency Medical Services
288 North 1460 West
Salt Lake City, Utah 84114-2852
Telephone: (801) 538-6435
Fax: (801) 538-6808
EMS DNR Directive: Section 75-2-1105.5
Attending Physician Responsibility
The
attending physician will have the responsibility to determine and diagnose
a terminal condition and explain that condition to the patient, and/or family
or legal proxy. The physician should explain the alternatives available through
the Living Will including DNR. The physician will also have the responsibility
to execute the physician determination on the appropriate EMS/DNR form, if
the patient should chose this option. The physician should counsel the
patient in
all options available to the patient.
The physician will issue the form, making sure that the Physician determination
section is filled out completely. The physician should not sign the form until
the patient has filled out the patient section and signed the form. After the
physician signs the form, witnesses must then date and sign the form as will.
The physician should make two copies of the form, give the original with the
watermark to the patient or proxy, keep one copy for the patient's medical record,
and mail or fax the other copy to the State Bureau of Emergency Medical Services
at the address shown on the form.
The physician will attach the bracelet to the patient or present the bracelet
to the proxy for placement on the patient. The physician will also inform the
patient that the directive may be revoked by an oral statement by the patient;
or by destruction of both the directive and bracelet/necklace. The directive
can be revoked by the proxy in the same manner. It can also be revoked by the
attending physician if he/she determines that the patient is no longer terminal.
Patient Responsibility
The patient must make an informed decision concerning resuscitation for cardiac
or respiratory arrest due to their terminal condition. The patient will inform
their family of their decision and the location of the EMS?DNR directive. They
should make their family aware of the appropriate areas for the directive to
be placed. The directive should be hung in an unobstructed view above the patient
on the wall or in close proximity to the head of the bed. If the patient is mobile,
it is highly recommended they were the approved bracelet/necklace that will be
easily recognized by EMS personnel.
They should further inform their family, that the directive can be revoked by
destroying both the written directive and the bracelet/necklace. Removal of the
bracelet will be considered to be destroying it. This can be done by the patient
or their proxy. They can also verbally state to the EMS personnel their desire
to be resuscitated should they arrest.
Family Responsibility
The family should be aware of the EMS/DNR directive, its location and the revocation
process. they should further realize that emergency medical services personnel
will respond should they be called either by calling 9-1-1 or the local emergency
number. But most importantly they should know and respect the wishes of the patient,
regardless of their own personal feelings. The family should also make a decision
as to whether or not they will want the patient to go to the hospital if they
call the EMS personnel.
EMS Provider Responsibility
The EMS personnel will be responsible to provide proper assessment of the patient's
status and the patient's personal needs through the completion of a primary and
secondary assessment of the patient. Remember, that the directive only applies
to cardiac and/or respiratory arrest in the patient as it is related to their
terminal condition and only in those situations where the patient has an active
and proper EMS/DNR directive in place, or when the have another aspect of the
Living Will that meets all the criteria that has been established for that part
of the Act.
The EMS personnel will determine the existence of the EMS/DNR directive as a
part of the patient assessment. The EMS personnel may need to begin resuscitation
efforts while they determine the status of the patient. Begin treatment of the
patient including CPR if the directive has been revoked. Avoid confrontation
with family. If the family demands care, provide palliative care while contacting
medical control and provide them with the information pertinent to the situation.
Remember, if an EMS/DNR directive is valid, the EMS personnel should honor the
patient's request by withholding CPR. If the EMS personnel have personal feelings
concerning the Directive and are unwilling to honor the directive, they should
allow someone else to assume responsibility for patient care. If the EMS personnel
should have any questions, they should contact medical control.
EMS Responsibility
The Bureau will print and distribute the EMS/DNR directive form and bracelets/necklaces
to the patient through their physician. The bracelet/necklace can be attached
to the patient as a support to the directive. In addition, the EMS Bureau will
maintain copies of all directives to track the patients and verify the Directives
for completeness and accuracy.
The EMS Bureau will also provide training for all EMS training officers concerning
the EMS/DNR rules, and training materials to assist in educating personnel. The
EMS Bureau will be a resource center to provide information concerning the rules
and implementation of the EMS/DNR directive, and assist in training all who will
fill out the forms to assure that they are done accurately.
Emergency Department Physician Responsibilty
(On-line Medical Control): The Emergency Department personnel need to understand
the EMS/DNR directive, how it is to be honored. In addition, they will act as
a support for the EMS personnel, intervene in the pre-hospital management of
a patient and interface with the attending physician, if it becomes necessary.
Other Health Care Workers' Responsibilities
Nursing homes, adult homes, hospitals, home health care nurses, and hospice units
should become educated concerning the EMS/DNR directive. They should be instructed
regarding the placement and removal of the EMS/DNR directive and/or bracelet/necklace.
They must understand the directive and the request of the patient, and honor
those wishes and not attempt to change or void the directive. They should not
attempt to force or coerce a patient into signing an EMS/DNR directive or any
other advance directive.
They will also be required to give the directive to the patient should the patient
leave their facility at any time after the directive has been written. The directive
must be presented to the EMS personnel upon their arrival if they are called
to assist or transport the patient. Any and all documentation of advance directives
should be readily available to EMS personnel when they are called to the scene.
General Information
The EMS/DNR directive is a single page document printed on white bond paper,
carrying the Great State of Utah watermark. It has a section entitled Attending
Physician's Determination, and a section entitled Declaration, and an area for
the signatures of witnesses. There is information on the back of the form to
identify who can act as proxy for the patient and who may witness the signatures
of the patient and proxy and the physician. There is also a section that will
be filled out and placed in the bracelet/necklace that will be given to the patient.
The original EMS/DNR Directive must be given to the patient and placed in an
unobstructed view above the patient on the wall or in close proximity to the
head of the bed (except in health care facilities where it will be placed in
the front or the patient's medical record). EMS personnel must see either the
EMS/DNR Directive or the bracelet/necklace to validate the Directive. One copy
shall be kept by the physician in the patient's medical file and one copy shall
be sent to the Bureau of Emergency Medical Services at the address shown on the
form. Any other copies of the form should not be made without express consent
of the patient or their proxy.
Remember only the original EMS/DNR directive will be honored.
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