DNR form:Nationally uniform and recognized

[fsunavybabe]

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I'm writing a paper on this topic, one which I've chosen and feel relatively strongly about from my work with hospice. I'd like to get some outside perspectives on it.

So, in FL they have this process where you can just print the form and sign it and get your doctor to sign it. You initial by the different contingencies you want to include (and blacken the others out). The problem with this document is that EMS can apparently choose to follow it based on whether it's printed on a white piece of paper or a yellow/gold piece of paper. For legal purposes, EMS only recognizes the DNR if it is printed on yellow paper. So then the patient gets to the ER and the doc has to decide whether he deems himself part of emergency services and thereby not having to follow a white sheet of paper or one who can determine and follow the patient's wishes as set down in their DNR.
Further complicating this is that EVERY hospital has it's own DNR form.

Is it like this in other states?
Would a federally made DNR form (with all the options: tube vs non tube fed, antibiotics vs none, etc) be a good solution?
Would that even be possible?

One issue is the authority of the feds to put out this form and get national recognition ... politically I could see the argument for this both ways but practically speaking with the shear #'s of medicare, medicaide and other federally funded health care programs, I'm not really going to tackle that issue too heavily.

Feel free to post links to resources about national DNRs.
Thanks SDN.

 

[deleted65604]

Seems like a decent idea. I wish I had a form like that a couple of days ago when a PEA cardiac arrest came in who had a history of end-stage throat cancer that had spread widely to his liver. It was one of those rare moments where ACLS actually works. Got him back and stabilized, except he had a fever, a WBC of 0.2, a big right sided pneumonia, and no meaningful neurologic activity. Incredibly, the man, his family, and his oncologist had never talked about end of life care. After ICU type resources and treatment for 2 hours, his family and I agreed that we should allow him to die.

Fun to practice intensive care, but poor use of resources.

 

[gutonc]

I'm writing a paper on this topic, one which I've chosen and feel relatively strongly about from my work with hospice. I'd like to get some outside perspectives on it.

So, in FL they have this process where you can just print the form and sign it and get your doctor to sign it. You initial by the different contingencies you want to include (and blacken the others out). The problem with this document is that EMS can apparently choose to follow it based on whether it's printed on a white piece of paper or a yellow/gold piece of paper. For legal purposes, EMS only recognizes the DNR if it is printed on yellow paper. So then the patient gets to the ER and the doc has to decide whether he deems himself part of emergency services and thereby not having to follow a white sheet of paper or one who can determine and follow the patient's wishes as set down in their DNR.
Further complicating this is that EVERY hospital has it's own DNR form.

Is it like this in other states?
Would a federally made DNR form (with all the options: tube vs non tube fed, antibiotics vs none, etc) be a good solution?
Would that even be possible?

One issue is the authority of the feds to put out this form and get national recognition ... politically I could see the argument for this both ways but practically speaking with the shear #'s of medicare, medicaide and other federally funded health care programs, I'm not really going to tackle that issue too heavily.

Feel free to post links to resources about national DNRs.
Thanks SDN.

Lots of states have what is called a POLST form (Physician's Orders for Life Sustaining Treatment). I am personally only familiar with the ones in WA and OR but a quick Google search shows that CA, MT, ID, UT, HI, WI and others have one or are developing one as well.
Look here for more details: http://www.polst.org/ (incidentally, this links to a page at my institution that I didn't know about until just now).

I doubt there will be a national form but a uniform method for this would be very helpful.

One thing that is being tried out now in OR is a statewide database that EMS can access on any patient via telephone. They give name and DOB and if a POLST form is on file, they are told what is on it and a copy is automatically faxed to the receiving ED. It's just a pilot program at the moment but the big problem with the POLST is that, unless it's stapled to the front door, with another copy stapled to the patient, nobody can ever find it when needed. I tell my patients to put it on the fridge with their med list but who knows if that actually happens.

 

[docB]

I think that such a form would be very helpful particularly a national one. A national form will never happen though because the states could never agree on one, the bureaucracy would doom it and it's probably unconstitutional to have such a form anyway.

I will recognize just about any form, note, scrawl, etc. that indicates the patients wishes if it goes along with the clinical picture. I figure my liability in that setting is limited. The problem I run into daily is that the public does not know the difference between an advanced directive and a living will. Everyone says they have an advanced directive (which is a DNR if it says not to resuscitate) but what they usually have is a living will. The living wills always start off with some language about "should I have a terminal situation with no hope of meaningful recovery then..." That's really not helpful in the ED where I have 5 minutes and really limited information before I have to decide to tube or not.

 

[Dwindlin]

I'm writing a paper on this topic, one which I've chosen and feel relatively strongly about from my work with hospice. I'd like to get some outside perspectives on it.

So, in FL they have this process where you can just print the form and sign it and get your doctor to sign it. You initial by the different contingencies you want to include (and blacken the others out). The problem with this document is that EMS can apparently choose to follow it based on whether it's printed on a white piece of paper or a yellow/gold piece of paper. For legal purposes, EMS only recognizes the DNR if it is printed on yellow paper. So then the patient gets to the ER and the doc has to decide whether he deems himself part of emergency services and thereby not having to follow a white sheet of paper or one who can determine and follow the patient's wishes as set down in their DNR.
Further complicating this is that EVERY hospital has it's own DNR form.

Is it like this in other states?
Would a federally made DNR form (with all the options: tube vs non tube fed, antibiotics vs none, etc) be a good solution?
Would that even be possible?

One issue is the authority of the feds to put out this form and get national recognition ... politically I could see the argument for this both ways but practically speaking with the shear #'s of medicare, medicaide and other federally funded health care programs, I'm not really going to tackle that issue too heavily.

Feel free to post links to resources about national DNRs.
Thanks SDN.

Ohio has a standardized form for the state with 2 options. DNR and DNR-CC. DNR means no holds bar up until cardiac arrest. DNR-CC means certain treatments aren't allowed period (cardiac monitor for example). For EMS to recognize it has to be completely filled out, signed by patient or POA and physician. Also, form has to be in my hand.

 

[deleted65604]

A few months ago, I came on shift 5 minutes after the previous doctor had intubated a DNR/DNI ALS patient.

The patient was very advanced and her only physical ability was to talk and breathe- barely.

Husband and wife had concluded that she didn't want to be intubated, but when she (presumably) got a mucous plug, went into respiratory distress, and started to die, husband panicked and drove her to the ER.

Previous doc leaves the building 5 minutes after intubation and goes home. I'm stuck with a sedated, paralyzed DNR/DNI patient. Try selling THAT admission.

After discussion with family, they requested admission over night while family could arrive and pulling the tube the next day.

She was taken off life support the day after, she said goodbye to her family and they were with her when she passed.

I still don't know what to think of the situation. I think we provided comfort to the patient and family.

Despite DNR orders, patients and family almost always want more done than they had thought. Most people can't watch other people die and not seek medical help. Most patients, in the panic and distress of dying, don't care what brave feelings they had before. They stop thinking rationally and 911 gets called.

Could loved ones be trained in the administering of rectal sedatives, or an IM shot when the time comes to ease the suffering better?

 

[MedicFL]

I'm writing a paper on this topic, one which I've chosen and feel relatively strongly about from my work with hospice. I'd like to get some outside perspectives on it.

So, in FL they have this process where you can just print the form and sign it and get your doctor to sign it. You initial by the different contingencies you want to include (and blacken the others out). The problem with this document is that EMS can apparently choose to follow it based on whether it's printed on a white piece of paper or a yellow/gold piece of paper. For legal purposes, EMS only recognizes the DNR if it is printed on yellow paper. So then the patient gets to the ER and the doc has to decide whether he deems himself part of emergency services and thereby not having to follow a white sheet of paper or one who can determine and follow the patient's wishes as set down in their DNR.
Further complicating this is that EVERY hospital has it's own DNR form.

Is it like this in other states?
Would a federally made DNR form (with all the options: tube vs non tube fed, antibiotics vs none, etc) be a good solution?
Would that even be possible?

One issue is the authority of the feds to put out this form and get national recognition ... politically I could see the argument for this both ways but practically speaking with the shear #'s of medicare, medicaide and other federally funded health care programs, I'm not really going to tackle that issue too heavily.

Feel free to post links to resources about national DNRs.
Thanks SDN.

Just to let you know that per state statue EMS can honor it even if it is copied on a white sheet of paper as long as it is all signed and in order. Its up to the local medical director to allow this or not which here they do. Another option is if the medics think (which I will admit many do not) you can call it in to the med control and request permission to honor it.

 

[GeneralVeers]

You should always err on what the patient would wish to happen. If I have any piece of paper with the patient's wishes, or family at bedside expressing what he/she would have wanted then I follow those decisions.

I think the liability for not following a DNR order when there is evidence that one is available is higher than for following one which may not be perfect.

 

[leviathan]

We have a nice 'level of intervention' form where I'm from, varying from level 1 (everything done except CPR and defibrillation) to level 5 (no abx, no iv fluids, no transport to hospital, etc) with options checked at the patient's will.

 

[Arcan57]

We have a POST form that has Resuscitate (yes/no), Care Level (everything, limited intervention (no unit/tube), and comfort care), Antibiotics (yes/no), and IV fluids. Most of our nursing home patients will have this on the chart. However, few of them are internally self-consistent and most are signed by the nursing home doc without family input. As such, we have DNR-CC patients in NAD transferred frequently and often the family does not know what I'm talking about re: DNR and wants everything done.

 

[willow18]

NY has a MOLST form (bright pink) in hospital charts; not sure if pt's get to take them home; in fact I highly doubt it. I think it's an excellent idea! I would also address the political concerns, e.g. the recent "Death Panel" scaremongering, amongst others. The legal implications of such a thing being under Fed jurisdiction can be another facet of this...

 

[GeneralVeers]

NY has a MOLST form (bright pink) in hospital charts; not sure if pt's get to take them home; in fact I highly doubt it. I think it's an excellent idea! I would also address the political concerns, e.g. the recent "Death Panel" scaremongering, amongst others. The legal implications of such a thing being under Fed jurisdiction can be another facet of this...

I actually think the "Death Panel" idea is great. Every patient should make their request known to their doctor/nursing home etc regardless of age or medical condition.

 

[willow18]

I actually think the "Death Panel" idea is great. Every patient should make their request known to their doctor/nursing home etc regardless of age or medical condition.

Ah General, if only your homies like Sarah Palin and so forth would stop being so reflexively against anything being proposed in a Democratically controlled congress. Okay, I'll admit, they have purer motives too: like energizing their anti abortion/condom/OCP/gays/sex ed/what did I miss 'base'.

 

[dmitrinyr]

NY has a MOLST form (bright pink) in hospital charts; not sure if pt's get to take them home; in fact I highly doubt it. I think it's an excellent idea! I would also address the political concerns, e.g. the recent "Death Panel" scaremongering, amongst others. The legal implications of such a thing being under Fed jurisdiction can be another facet of this...

Last year I worked in a NY hospital as a medical intern. Yes we had the pink MOLST form but there were certain rules that had to be followed. For example, if you came in with a copy of the pink MOLST form or a Nursing Home DNR, the doctor in charge of the pt still had to fill out a pink form and get concent from family within 24 hrs (or 48 hr I cannot remember) for the pt to be declared to have a DNR status. This was always annoying in situations when you have a pt that's s/p cardiac arrest from a NH who has a valid NH DNR but the ED still would code this pt again as he did not have a pink for filled out. This wasn't that often but when it happened (or a similar case) it was time-consuming and resource depleting.

 

[GeneralVeers]

Ah General, if only your homies like Sarah Palin and so forth would stop being so reflexively against anything being proposed in a Democratically controlled congress. Okay, I'll admit, they have purer motives too: like energizing their anti abortion/condom/OCP/gays/sex ed/what did I miss 'base'.

Sarah Palin is not my "homey". I'm an atheist, pro-abortion, pro-science Conservative. Yes, such things can exist.

 

[willow18]

Last year I worked in a NY hospital as a medical intern. Yes we had the pink MOLST form but there were certain rules that had to be followed. For example, if you came in with a copy of the pink MOLST form or a Nursing Home DNR, the doctor in charge of the pt still had to fill out a pink form and get concent from family within 24 hrs (or 48 hr I cannot remember) for the pt to be declared to have a DNR status. This was always annoying in situations when you have a pt that's s/p cardiac arrest from a NH who has a valid NH DNR but the ED still would code this pt again as he did not have a pink for filled out. This wasn't that often but when it happened (or a similar case) it was time-consuming and resource depleting.

Agreed; there probably should be a universal DNR and that's it. The issue that lies at the heart of all of this is that the people who create these forms don't work on the 'real world'.

Sarah Palin is not my "homey". I'm an atheist, pro-abortion, pro-science Conservative. Yes, such things can exist.

I was just kidding; I respect you enough not to think that you actually think anything of that woman. I'm somewhat of a mutt myself, but the current state of the 'conservative' movement (particularly with their bible-thumpin obsession about social issues) forces me somewhat to the left. On health care though, I don't have anybody to side with; it's just two parties adhering to whoever is paying them. AHIP vs TLA.

 

[GeneralVeers]

I was just kidding; I respect you enough not to think that you actually think anything of that woman. I'm somewhat of a mutt myself, but the current state of the 'conservative' movement (particularly with their bible-thumpin obsession about social issues) forces me somewhat to the left. On health care though, I don't have anybody to side with; it's just two parties adhering to whoever is paying them. AHIP vs TLA.

I agree. Neither party is really suggesting the changes necessary to make healthcare delivery more effective. We need to have true market-driven health insurance, but the insurance companies are busy protecting their monopolies, and the greedy unions are trying to protect their Cadillac plans.

Here's what needs to happen:

1. Get rid of Employer-based health insurance. Give everyone a tax credit when they buy their own insurance. This would allow people to spend their own money on the plan that they choose.

2. Allow all insurance companies to sell insurance in all 50 states, which would work to break up the monopolies and force competition. This would bring rates down.

3. All public plans would require out-of-pocket contributions to discourage overuse of healthcare. In the case of Medicaid, if you visit the hospital then you would have $10 deducted from your next Welfare check.

4. Insurance companies could not turn away anyone due to pre-existing conditions, HOWEVER they have the right to charge whatever premium they feel is appropriate.

5. Give doctors the right to discontinue "futile care". If done effectively it will make a small, but noticeable impact on premiums and Medicare costs.

 

[Dr. Wexler]

4. Insurance companies could not turn away anyone due to pre-existing conditions, HOWEVER they have the right to charge whatever premium they feel is appropriate.

How is this any different than allowing them to exclude pre-existing conditions? Rather than actually exclude them insurance companies could (and would) de facto exclude pre-existing conditions by making rates so astronomical no one with a pre-existing condition could afford the premium.

 

[GeneralVeers]

How is this any different than allowing them to exclude pre-existing conditions? Rather than actually exclude them insurance companies could (and would) de facto exclude pre-existing conditions by making rates so astronomical no one with a pre-existing condition could afford the premium.

There is no way to make insurance companies include everyone and keep premiums low. If you forced insurers to cover everyone with pre-existing conditions at rate with a maximum cap, then logically the rates for everyone else would go up astronomically as well in order to cover the sick. Additionally it creates an incentive for otherwise healthy people to wait until they get sick to obtain coverage, again raising the premiums for everyone else.