DNRs in the field: EMS providers face conflicts

Patient wishes may conflict with provider training

With more terminally ill patients receiving care outside the hospital, in hospices, home health or in nursing homes, it is becoming increasingly common for emergency medical service (EMS) providers to encounter patients with advance directives or living wills that ask that they not be resuscitated or that certain lifesaving measures not be performed should their hearts stop beating.

But complying with the person’s wishes may be difficult or often impossible for EMS providers. State laws and local medical supervision policies may place specific restrictions on what decisions EMS personnel can make in the field. And the providers — which can be paramedics, firefighters, or police officers — may lack the training and background to feel comfortable making such decisions, particularly when the issue is what resuscitative measures the patient wants or does not want.

"We have had a lot of difficulty when people want more of a say in what can happen and can’t happen in an individual situation," says Robert R. Bass, MD, FACEP, chairman of the American College of Emergency Physicians’ (ACEP) Emer-gency Medical Services Committee, and the EMS director for the state of Maryland. "You can’t have a five-page document written by a lawyer readily interpreted [by EMS personnel] while someone is in extremis and you’re trying to figure out what you can do or can’t do."

In some cases, EMS providers are called to the home of a terminally ill patient by the family, which doesn’t understand that local policies in their area may require the providers to attempt resuscitation in the event cardiac arrest occurs and there is no immediately available documentation that the patient did not wish it, says Catherine Marco, MD, FACEP, chair of ACEP’s ethics committee, and a practicing emergency physician in Ohio.

"For example, you have a terminally ill cancer patient at home and the family panics and calls 911 when the person stops breathing," she explains. "The paramedics get there and they say, Oh no, he doesn’t want to be resuscitated. We didn’t know what was going on, and we just wanted some help.’ But the paramedics say that unless they can produce the advance directive, they must go ahead and do everything."

Marco has seen many distraught families arrive in hospital emergency departments with a resuscitated patient who are adamant that this was against the person’s wishes.

Many states are trying to move to a standard form for do-not-resuscitate (DNR) orders that would be applicable both in hospital settings and in the field, say Marco and Bass.

Maryland currently has a state-approved standard policy for EMS providers, but is moving toward a uniform policy that would be simpler and could be used across settings, says Bass.

"Right now, [EMS] basically puts people in two categories. We have people we will do absolutely nothing but provide palliative care, and a second category of people where we will do everything up to a [cardiac] arrest," he says. "Then, if they arrest, we don’t resuscitate."

Over the years, he has seen people who wanted to be defibrillated but did not want CPR, or did want CPR but did not want to be intubated, or did not want to be intubated, but did want an IV line, etc., Bass says. Such distinctions may be appropriate for terminally or seriously ill patients in a hospital, but are almost impossible for EMS personnel to conform to.

Maryland currently is revising its standard policy in the hopes of making it easier to understand and apply. The hope is that patients and physicians will use it across the spectrum of care.

"A lot of patients and some of the doctors have trouble understanding why EMS cannot accept a living will," he says.

Ohio also has a state-approved DNR order, instituted just last year, but providers have a long way to go in educating the public, says Marco.

"There is still a big gap in public awareness and utilization of the standardized DNR order," she says. "When the patient takes the initiative to complete the form, it is great because everyone feels happy about complying with that person’s wishes. But it is still extremely rare that we see someone with a completed state advance directive."

ACEP has had a policy to guide states and EMS providers on establishing "do-not-attempt-resuscitation" (DNAR) orders in the pre-hospital setting since 1988, Marco notes (see guidelines, below). But the policy has had little impact, she says.

Marco and colleagues recently surveyed EMS providers nationwide for an upcoming study in the Journal of Emergency Medicine, she says. They found significant variation among states and providers about how resuscitations were handled.

The ethics and EMS committees will work together on revising and updating the ACEP policy this year, Marco says.

"It is premature to discuss it in detail, but overall our goal would be to foster more consistency in how we handle the problem," she says.

Guidelines for Developing Field DNAR Policy

A comprehensive do-not-attempt-resuscitation (DNAR) policy should be endorsed by the local, regional, and state medical community and EMS governing body. Where possible, legislative support for such a policy should be sought. The DNAR policy should:

  1. Establish the fact that basic and advanced life support may not be appropriate and/or beneficial in most clinical settings.
  2. Reiterate the need for a presumption in favor of resuscitation when the patient’s wishes are not known.
  3. Define the conditions under which a DNAR order can be considered.
  4. Define which patient is competent to agree to a DNAR order and establish a mechanism for determining a surrogate when the patient is not competent to reach such a decision.
  5. Establish that the decision not to attempt resuscitation must be an informed decision made by the patient or his surrogate.
  6. Identify the information that should be contained in an out-of-hospital DNAR order and the authority that will be responsible for developing such a mechanism.
  7. Identify the clinical procedures that are to be withheld in the execution of a DNAR order (or identify which authority will establish these withheld procedures).
  8. Define the exact manner in which the DNAR order is to be executed, including the role of on-line medical direction; each system should have two-way radio capabilities to permit access to that on-line medical direction.
  9. Define the procedure for revocation of a DNAR order.
  10. Establish a procedure for periodic review of such an order.
  11. Establish immunity for health care providers who carry out a DNAR order in good faith.

There should be an option not to observe a DNAR order if:

  • The patient is able to express a wish to be resuscitated prior to cardiopulmonary arrest.
  • The pre-hospital personnel have any doubts about the authenticity of the DNAR.

A DNAR policy should also include a mechanism for ensuring the proper pronouncement of death, for disposition of the body of the deceased and a mechanism for grief counseling. Prior arrangements should be made with the patient’s attending physician, local coroner or similar authority, and funeral directors.

A DNAR policy should also include procedures for ensuring that organs that have been donated by the deceased can be procured appropriately.

Finally, a DNAR policy should include an educational program for patients, their families, and the medical community regarding the appropriate use of the EMS system in the treatment of terminal medical conditions.


  • Robert Bass, MD, FACEP, and Catherine Marco, MD, FACEP, American College of Emergency Physicians, 1125 Executive Circle, Irving, TX 75038-2522. Telephone: (800) 798-1822.