What Would You Do?

I was working at my part-time job the other day, and we got into a lengthy discussion about Do Not resuscitate orders and when to honor them versus when to treat a patient.  Today, the conversation continued and we came up with an interesting scenario, and I wanted to see what everyone out there thought both from a moral/ethical stand point as well as a legal one.
Here’s the story:

You are called to the home of an 80-year-old male who lives alone.  His neighbor frequently checks on him.  Today, his door is locked, which is unusual.  Your unit arrives at the same time as the fire department who is there to help you gain entry and assist with patient care.

You enter the patient’s apartment and find him supine on his couch.  His breathing is clearly agonal and you cannot detect a pulse.  In plain view sitting on the coffee table in front of him are the following:

  • A bottle of hydromorphone which was filled two days ago.  The cap is off and the bottle is empty.
  • An appropriately filled out Do Not Resuscitate order which clearly states that the patient does not wish to have CPR performed on him.
  • A suicide note stating that he had been recently diagnosed with cancer and does not want to live anymore.  It outlines what he would like to be done with his personal effects.

What would you do?  Would you start CPR on the patient?  Would you honor the DNR?  Does the suicide attempt void the presence of the DNR?

Normally, I would expect a bunch of comments on this topic to say “I would contact medical control to see what they would like me to do.”  While I understand that, I would like to know what YOU would do as a provider.

Also legal folks, I know you’re out there, what do you think?

  • Fairmontfire

    Since it was not natural and murder is possible I would attempt to resuscitate.

  • Rodriguez90210

    I’d honor the DNR. If he doesn’t want to live that’s ok with me.

  • BH

    A DNR is a medical decision made by a person “of sound body and mind.” Suicidal ideation, at least in my state, renders one automatically incompetent to make decisions or refuse care (akin to intoxication, essentially).

    So, we work it. And take the note.

  • Nadams

    Sorry to say, but in my opinion, the pt’s DNR would be null and void in this situation. #1 it is illegal to kill yourself, and #2 people with suicidal ideation have no rights to deny patient care (dead or not). It is clear in this situation that the patient intentionally took medicine to “off himself”, so the DNR is not to be enforced.

  • http://www.facebook.com/profile.php?id=100000059649868 Eric Hatcher

    Going with the CYA approach I’d begin treatment. I’d rather be called out for doing something over doing nothing.

  • Noregrets_tiffany

    He has a DNR, id honor it. It should be his decision to choose to live or die. Especially under the circumstances. If you dont honor it you also know damn well you are going to get sued

  • Katie

    Void. Period.

  • JME

    Full rescus (tube / IV Narcan) minus active CPR, still apply the O2 via BVM though. That is not ‘technically’ active CPR, I’m doing what I can while staying within moral, ethical, and legal bounds (to me at least). How am I to KNOW this was an actual suicide and not something else? How do I KNOW the patient took the meds found?

  • Azza

    DNRs I thought were for specific cases, if it was caused by certain thing then that scenario I would honour. For instance, if it was caused by the cancer then would honour, a trauma then carry out CPR. If it states under any circumstance I would honour it. It also needs to have been witnessed and signed appropriately.

    In terms of suicide I would probably call control for advice as it is not a natural cause. I would start CPR while waiting for the response, if told to honour I will stop and record what happened on my paperwork as well as informing control.

  • Jarvis Rl

    Who’s my partner? Who are the fire and police guys that are on scene with me? Is there a student on scene? More importantly, how close to end of shift am I?

    Clearly I ask these in jest. I think you already know my answer. The decision to have a DNR is not one that is made in a day; it takes time and careful thought. It is made of someone of sound mind. Being suicidal does in fact make you “not of sound mind and unable to adequately make decisions for yourself.” However that fact does not wipe out every decisions you made in your life that was “of sound mind.” Personally, I would honor the DNR. But I know our MedCon will and has backed us up on any situation that we chose to work a DNR code that was unusual/ confusion/suspicious.

  • http://www.facebook.com/profile.php?id=1515673933 Jon Drake

    As the voice of Devil’s Advocate (or Count Chocula if you prefer):
    People are deciding to resuscitate this gentleman because it’s “illegal” to kill yourself? Why? So that he may continue to suffer through the ravages of cancer, and now, potentially in a vegetative state if our efforts are somewhat successful or in a nursing home or other institution under the stigma that he has attempted to end his own life if our efforts are truly successful. We are throwing out compassion and care for our patient because of a grey area in our legal system, namely, that physician assisted or self induced suicide in the face of terminal illnesses is unlawful because our lawmakers do not have the courage to allow individuals to make decisions on their own. DNR’s are not cause specific and in most cases they will not list an underlying condition, simply because ANYONE can get one, sick or not. What we as field caregivers are losing sight of is this man, at some point recognized that his illness was terminal and he wanted to go out with dignity and respect, not with a bunch of ambulance drivers beating on his chest, electrocuting him, then stuffing a tube down his throat and jamming pharmaceuticals into his veins. His DNR should be honored, and he should be allowed to die peacefully since that was his choice.

    And trust me, I have not disregarded the post incident ramifications either. But having been through a similar situation many moons ago, if you clearly document and explain your reasoning, be it to a police officer, a state investigator or in front of a jury, people are more than likely going to agree with your decision as a compassionate and understanding caregiver since they someday may have to make a similar decision in their own lives about their own mortality.

    • BH

      If he died from the cancer I’d be with you 100%. Unfortunately, he took that option away from me when he took an active measure against his life.

      • http://www.facebook.com/profile.php?id=1515673933 Jon Drake

        A couple of points to ponder in regards to the myriad responses.

        1. Has any paramedic or EMT ever lost their state card due to either not honoring or honoring (under abnormal circumstances) a DNR? There are plenty of experienced providers on this blog who know dozens, if not hundreds of other providers. To my knowledge, and it is difficult because of a lack of uniform reporting from agencies having jurisdiction, no one has ever been sanctioned to the point of losing their card. In addition, is anyone aware of any civil litigation against a prehospital provider for the same circumstances?

        2. @BH, you said that he took that option away from you when he took an active measure against his life. In retrospect, isn’t the DNR a similar action? It’s HIS life. I’m only a paramedic, not a god, demi-god or any other higher power. If this gentleman chooses to end his life by his own hand, knowing full well that he has a DNR in place, why should we be forced to step in and controvert his decision?

        3. I saw someone mention a show code. If you aren’t going to do things according to protocol or the standard of care, why do them at all? Why further expose yourself to unnecessary risk?

  • flytmedic0587

    I would recognize that being suicidal and making the attempt such as he did would not constitute “being of sound mind” which legally negates the DNR. With that said, I would start ALS treatment and yes contact medical control and hopefully not have to do CPR.

  • Kimee129

    Legally speaking the DNR is null and CPR should be started. However, having watched someone die a slow, miserable, painful death from Cancer…I would probably not start CPR. This man was 80 years old? I would of hoped he led a long life. He most likely was of sound mind and body when he decided to take the pills.

  • Roxley

    In Georgia, the DNR has to be signed by a Dr., making it an order filled out in advance and assuming the doctor has determined the pt.’s mental status. Step back and call the coroner.

  • The DL

    If the neighbor had not arrived all would have gone as the gentleman had planned. I would go along with his wishes — and were I in his position I would hope that my wishes would be followed. But, then, I live in a very small town where everyone knows one another and I probably would have some insight into this gentleman’s life. I say “let him go” — fire me, I’m a volunteer, but does it make it different being a “paid professional?”

  • http://notesfrommosquitohill.com mack505

    Good one, Scott. I’m afraid my ethical, legal, and moral senses have a head-on crash here. With airbag deployment and entrapment.

    Moral sense says this was a rational decision on his part and we should let him go. The desire to control ones own destiny when faced with a terminal situation is strong.

    BUT I know the Commonwealth says if there’s any question we should consider the DNR void and work the patient. I dont like it, but that’s my understanding of the law. I hate CYA medicine, but in the end I love my career.

    I’m afraid I end up working him and hoping we fail.

  • Duane_y

    CYA, “Show Code” and let him go HIS way…

  • Fern the Fire-Rescue newbie

    DNR = Do Not Resuscitate.

    Therefore, those sum up my Plan A.

    Plan B calls for a phone call with a Doc.

  • Fern the Fire-Rescue newbie

    I should mention that Plan A and B are interchangeable, depending on my partner’s opinion.

  • Railrob

    In 40 + years of EMS I have lived by one rule, do what is right for the patient. For this, I have never had legal issues with my patient care. I have had the pleasure to work with the same group of ER docs for 20 of those years. My fellow medics and I have addressed this question along with our medical control many, many times. Each time we have gone with doing what was right for the patient and not the other systems have been worried about here. When I asked my current medical director this question he replied that we shouldn’t put this patient through the touture we call a code.
    Let the man die a peaceful death.

  • DoctorGoodleg

    I’m going to go from another angle. Whatever you all decided, it was with a clear thought process, and a professional, compassionate attitude also based on your knowledge. If any of you were my partner and explained it the way you did, I’d have very litle problem with any of these rationales.

    The fundamental problem with this case is that we as providers are not entrusted as medical professionals to make these types of decisions…we are judged to be not as qualified as others. Thisis partly the people we work for, partly our own fault.

    We need to be at the table in medicine. This means increasing our standards of education, and standards of care. We need to make “ambulance driver” a bad word in our profession. We need to demand respect from our counterparts in the hospitals. We need to do research to prove that good pre hospital care reduces morbidity, mortality, and indirectly health care costs. We need to show that prehospital medicine is not something everyone can do, much like physicians, the military, and firefighters.

    When we’ve accomlished that, this dilemma will be easier, because we will be able to make strong, ethically sound and medically acceptable decisions. Without calling for permission.

  • S G Kallmeyer

    I must have had the lord bring me here because the question is hitting home i am a terminal cancer patient (renal) with possible Metasis of liver) i am coming off dialaudid as i type due to my doctor being in his last yr of residency so he has a attending but last month he presrcibed 4mg every 8hrs as needed.I would only use them when i did not want to chase the pain.Now i know from the question this is tough I too have DNR and Advance Directives in place yes it ties all EMS on sight protocols and some Er protocols,I am a former EMT and would have finished my state boards to be a RN but a horrific car crash changed that.I have been on dilaudid before when i lost my right kidney to this same disease except i did not have pain i did not even know i had a 4.8 cm tumor clear cell.I ask this question to men women i respect, i believe my doctor did this not just because of the laws that govern or police doctors due to abuse by other;s but because without biopsies they have no idea what stage they believe grade 4 now i went from 180 in december to 153 as of 6 days ago do i let beurcracy determine whether i do not do the biopsies because it has been told to me that i could lose the L kidney and have to rely on dialysis which does not work for me.I have close caregivers/friends who are executors only 2 can change the DNR order.But as i told my docs nurse I am tired i have dealt with the inception of this disease called cancer when it came back in 2011 went away came back in january 2012 so bad that they want to search for metasis of the bones.I am at a loss as to whether just go into full withdrawls call EMS to see hope my heart does not stop so this question your asking never has to be used in a legal point.

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