VII. Appendix

I. INTRODUCTION

These guidelines are intended to assist local emergency medical services (EMS) agencies in developing Do Not Resuscitate (DNR) policies. DNR policies allowing patients to refuse unwanted resuscitation attempts ensure that patients' rights are honored and are a necessary part of EMS systems.

The revision of the guidelines is prompted by interest in standardized documents that will be
recognized statewide, including the use of an optional DNR bracelet/medallion.

Despite the focus on standardization, local EMS agencies and providers must go through a local process involving all interested groups; local decision-making is essential in this sensitive area. Most importantly, DNR policies will be meaningless without awareness of the availability of prehospital DNR options, especially among non-EMS physicians and their patients.

II. BACKGROUND

The goals of emergency medical services personnel include saving lives, preventing disability and relieving suffering. Historically, EMS systems focused on sudden cardiac death and resuscitation. Patients were treated to the fullest extent possible, and discussions about patients' wishes regarding resuscitation or the extent of treatment were reserved for medical personnel in acute care facilities.

More and more frequently, however, patients or families of patients resist resuscitative measures. They view resuscitation attempts in selected patients as lacking sufficient benefit and merely prolonging the process of dying, while causing unnecessary discomfort and emotional distress. These patients are generally, although not always, victims of terminal illnesses, and are encountered in skilled nursing facilities, private residences and other care settings. They may or may not be clients of hospices.

Historically, patients not wishing resuscitation were discouraged from activating the EMS system since emergency responders generally were obligated to initiate full resuscitative measures and these were usually continued until arrival at a hospital. Discouraging patients from using the EMS system when they do not wish resuscitation avoids difficult problems, including identification issues, but may deny patients palliative treatment, an important obligation of all health care providers. In some, cases, these patients must use the EMS system solely to obtain transportation, sometimes forcing them to accept unwanted resuscitative measures.

Despite pre-planning not to perform resuscitation, family members and employees of skilled nursing facilities frequently activate 9-1-1 when death is imminent. Performing resuscitation against a patient's wishes in this case is inappropriate because it denies them real authority over their health care.

In addition to providing palliative care for patients, prehospital professionals may benefit families by assisting in determining when death has occurred. This may be an appropriate role for the EMS system though it should be restricted to private residences and not to licensed facilities which should have alternatives for determining death.

While it is clear that care givers should acknowledge patients' wishes in regard to resuscitation, caution is needed in the field setting since there is generally no established relationship between the patient and emergency responder, the patient is seen under emergency conditions and accurate identification may be difficult. Specific procedures are needed whereby legitimate DNR directives will be respected in the home and long term care facility and during transport. This is best dealt with by standard requirements for DNR directives and clearly written policies and procedures for local EMS providers.

III. AUTHORITY

In cases of sudden, unexpected cardiac arrest, treatment consent is not possible and EMS systems operate on the principle of implied consent. Many cases of cardiac arrest, however, may be anticipated because of the patient's age or medical condition.

Cardiopulmonary resuscitation is similar to other medical interventions with advantages and disadvantages, risks and benefits. When possible, patients should give informed consent before resuscitation is attempted, or at the very least the patient's physician should understand the patient's wishes regarding medical care. Patients' rights to consent to or refuse resuscitation or other recommended medical care do not depend on the presence or absence of a terminal illness or the agreement of their physician.

Professional guidelines for cardiopulmonary resuscitation reflect the idea that consent is possible and desirable, and that resuscitation is not always appropriate. The American Heart Association 1992 "Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care" point out that emergency cardiac care:

"attempts to restore those hearts too good to die, it should not attempt to restore 'hearts too sick to live .' CPR and ECC (emergency cardiac care) restore this process of living, not prolong the process of dying. When a patient reaches the end of his or her life, continued resuscitative efforts are inappropriate, futile, undignified, and demeaning to both patient and rescuers."

The Patient Self-Determination Act of 1990 requires health facilities receiving Medicare or Medicaid funds to give patients information regarding advance directives. The Joint Commission for the Accreditation of Health Care Organizations requires defined procedures to make resuscitation decisions in accredited facilities.

California courts fully support the rights of individuals to determine the course of their own
health care:

"...If the right of the patient to self-determination as to his own medical treatment is to have any meaning at all, it must be paramount to the interest of the patient's hospital and doctors. The right of a competent adult patient to refuse medical treatment is a constitutionally guaranteed right which must not be abridged."

Bartling v. Superior Court
163 Col. App. 3d 186, 195 (1984)

Courts have, in fact, found that patients' rights to control their own medical treatment usually are paramount to any state or personal interest, including the preservation of life or the maintenance of the ethics of the medical profession. Perhaps the only state interest that may be found paramount to the patient's right to refuse treatment in individual cases is the protection of innocent third parties, such as minor children.

The EMS system, as the extension of medical practice into the field, has the same ethical obligations to honor patient wishes regarding resuscitation. Do not resuscitate directives are a critical part of any EMS system. Patients cannot be refused their legal and ethical rights to consent to or refuse medical care simply because they are in the prehospital setting.

EMS medical directors are responsible for the medical direction and management of EMS systems (California Health & Safety Code, Sections 1797.220 and 1798), and have the responsibility, authority and ethical obligation for implementing DNR directives.

IV. FACILITIES

In licensed facilities such as acute care hospitals and skilled nursing facilities (SNFs), DNR orders are usually written as a simple physician recording of "do not resuscitate", "no code", or "no CPR" in the patient's medical record. This method is simple and easy, but lack of uniformity between individual physicians and various facilities may leave prehospital care providers uncomfortable honoring this type of DNR order. This places undue burden on the emergency responders. Prehospital providers would immediately recognize a standardized DNR form and be reassured about the validity of the directive.

Nursing homes frequently rely on EMS providers for emergent care of patients, as well as for transportation between facilities. Case law regarding patients' rights to control their medical care in health facilities is reflected in the following subsections of Title 22 of the California Code of Regulations governing skilled nursing facilities:

"72527(a) Written policies regarding the rights of patients shall be established and shall be available to the patient, to any guardian, next of kin, sponsoring agency or representative payee and to the public. Such policies and procedures shall ensure that each patient admitted to the facility shall have the following rights and be notified of the facility's obligations:..."

"72527(a)(4) To refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal."

Emergency medical responders have neither the time during an incident nor the expertise to determine whether DNR orders, other than those contained in local EMS protocols, meet regulatory requirements. When DNR orders are written in a long term care facility or other licensed facility, the burden for determining the appropriateness of the order and compliance with regulatory requirements lies with the facility administration and the patient's physician, not the prehospital care provider.

Information regarding the necessary components of appropriate DNR orders in long-term care facilities may be found in "Guidelines Regarding Withdrawal or Withholding of Life-Sustaining Procedures(s) in Long-Term Care Facilities" (See reference 7).

Hospices care for the physical and emotional needs of terminally ill patients. These persons receive care and assistance from hospice workers while spending their remaining time at home. These patients, their families, or legal representatives have decided they do not wish resuscitation attempts. Generally, the EMS system is not activated at the time of death, although occasionally this happens for reasons discussed previously.

The following guidelines present an outline for policies and procedures for honoring DNR requests. These statewide guidelines:

Support the necessity of DNR directives in prehospital care.
Provide a framework that will offer some legal protection to EMS agencies and EMS providers.
Safeguard the personal and professional integrity of those providers. Give patients the authority over their health care to which they are morally and legally

V . IMPLEMENTATION PROCEDURES


1. All local EMS agencies must offer potential patients the opportunity to refuse unwanted cardiac resuscitation, both basic and advanced life support. This should apply to patients in long-term care facilities, during transport between facilities, and in patients' homes. Two instruments are used to assure standard implementation, the statewide DNR Form and a standard medallion.

Patients have near-absolute authority to refuse resuscitation. The role of the physician signing the DNR directive should be to evaluate the patient for untreated or inadequately treated illness where additional treatment might change the patient's decision regarding resuscitation

. The physician should ensure that the patient understands the meaning of resuscitation and "do not resuscitate," explain the benefits and risks of a resuscitation attempt, and answer any questions the patient may have.

2. a. Do not resuscitate (DNR) means no chest compressions, defibrillation, endotracheal intubation, assisted ventilation, or cardiotonic drugs.

b. The patient should receive full palliative treatment for pain, dyspnea, major hemorrhage, or other medical conditions.

c. Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped and the patient is unconscious, ventilation should not be assisted.

3. a. The California Emergency Medical Services Authority (EMSA) and the California Medical Association (CMA) have approved a standard DNR form that will be used statewide for prehospital DNR requests. This form is available from the CMA through Sutter Publications, and from local EMS agencies, community-based organizations, county medical societies, health care facilities, and physicians under local EMS agency policies.

b. Requests must be signed and dated by a physician. No witness to the patient's or surrogate's signature is necessary. Ensuring appropriate informed consent is the responsibility of the attending physician, not the EMS system or prehospital provider.

c. The DNR Form should be clearly posted or maintained near the patient in the home. A typical location might be in an envelope in a visible location near the patient's bed. Copies of the form are valid and will be honored. The patient or family should be encouraged to keep a copy in case the original is lost. The copy should be taken with the patient during transports.

d. In general, the EMT should see the written prehospital DNR Form or medallion unless the patient's physician is present and issues a DNR order.

4. Correct identification of the patient is crucial, but after a good faith attempt to identify the patient, the presumption should be that the identity is correct if documentation is present and the circumstances are consistent. There should be a properly completed standard EMSA/CMA DNR Form available with the patient. A witness who can reliably identify the patient is valuable.

5. The most accurate form of identification for patients outside of licensed facilities is a medallion or bracelet attached to the patient. Use of such a medallion should never make the patient uncomfortable and should always be optional. The bracelet or medallion should also be standard in each county and have controlled availability so that it may, by itself, be immediately honored.

The California EMS Authority will use a policy to establish a standard medallion (see Appendix C) and medallion manufacturers must agree to comply with EMS Authority guidelines in order for their medallions to be recognized by prehospital personnel. The medallion should be engraved with the words "Do Not Resuscitate-EMS." Medallions should only be issued after receiving a copy of the completed EMSA/CMA approved DNR Request Form from an individual.

6. In licensed health facilities (e.g. skilled nursing facilities, hospices, intermediate care facilities) DNR orders written by a physician in the medical record are to be honored. The facility staff must have the patient's chart with the DNR order recorded in it immediately available for rescue personnel upon their arrival. However, facilities are encouraged to use the EMSA/CMA approved DNR Form to avoid confusion and potentially unwanted resuscitation.

The emergency medical services system must not be used simply to pronounce death in nursing home patients. Inappropriate use of EMS Personnel simply to pronounce death of patients should be addressed by service providers and/or EMS agencies. DNR orders are aimed at patients who may suffer cardiac arrest during treatment or transfer.

7. a. Base hospital physicians retain authority for determining the appropriateness of resuscitation. Emergency medical technicians in the field have the ability to contact a base hospital and advise the physician of the details of a particular case if resuscitation appears unwarranted or unwanted by the patient. While field circumstances make this type of ad hoc decision difficult as a routine procedure, it may still apply to specific cases where patients' wishes are known and explicitly expressed.

b. The role of the base hospital should be defined. In some cases the base hospital will not be notified and all documentation will appear only on the patient care record. Other jurisdictions may wish to have the base hospital consulted.

c. In unusual cases where the validity of the request has been questioned, emergency responders should be allowed to temporarily disregard the DNR request and institute resuscitation measures while consulting their base hospital for assistance.

8. a. If the patient is conscious and states that they wish resuscitative measures, then the DNR Form should be ignored. In rare instances, when the patient is unable to state his or her desire and a family member is present and requests resuscitative measures for the patient, the family member's objection may call into question the validity or applicability of the DNR Form. Although the patient's wishes or instructions should remain paramount, resuscitation may be undertaken until the situation is clarified. Usually discussions with the family will make attempted resuscitation unnecessary.

b. Clarification may require only discussion with the family member, with explanation, reassurance, and emotional support. Assistance from a base hospital may be helpful. Again, the underlying principle is that the patient's wishes should be respected.

9. Local EMS agencies should have policies addressing the use of documents other than the EMSA/CMA approved DNR Form (see Appendix A). Individuals who state that they are the "attorney-in-fact" (see page 11) for a patient and decline resuscitative measures on behalf of the patient should present identification and document the decision by signing appropriate forms. The base hospital may be contacted for consultation. Other instruments such as Declarations" under the Natural Death Act, or other DNR requests should be handled through base hospital contact according to local EMS policies.

10. Emergency medical technicians should attach a copy of the approved DNR Form to the patient care record, along with other appropriate written documentation. The DNR Form should accompany the patient so that it may be incorporated into the medical record at the receiving facility. When DNR orders are noted in medical records in licensed facilities, that fact should be recorded by the EMT, along with the date of the order and the physician's name. It should be noted on the patient care record that a written DNR order was present including the name of the physician, date signed and other appropriate information.

11. Patients who are dead at the scene should not be transported by ambulance, however, local EMS agencies should consider policies for DNR patients who collapse in public locations. In these cases it may be necessary to transport the individual to a hospital even without resuscitative measures, in order to move the body to a location that provides the family with more privacy and where arrangements can be made more expeditiously. Local policies shall have the approval of the Medical Examiner/Coroner, who has the responsibility for investigating all deaths with other investigative bodies.

Vl. BACKGROUND MATERIAL ON OTHER ADVANCE DIRECTIVES

These guidelines have focused on the standardized prehospital DNR Form, and physician DNR recordings in licensed facilities as the preferred methods for honoring patient decisions to forego cardiac resuscitation. There are several additional written documents or instruments that may be encountered. Local EMS agencies should decide what role, if any, these written instruments play in the prehospital care system. At the very least, emergency responders and base hospital personnel must be aware that these instruments exist and may be presented to the emergency care providers by patients or their families.

There are a variety of " living wills" available from many sources. While these may communicate to the rescuer some sense of the patient's wishes regarding resuscitation, the wide variety of these documents and the inability to confirm the legitimacy of the orders makes them unsuitable for emergency use without prior confirmation. A base hospital may, however, elect to use these in guiding a patient's therapy.

One legal instrument that may be encountered is the California Durable Power of Attorney For Health Care (DPAHC) found in Civil Code Sections 2430-2445. This document allows individuals to appoint an "attorney-in-fact" to make health care decisions for them if they become incapacitated. (The attorney-in-fact is prohibited from consenting to certain treatments, including placement in a mental health facility, convulsive therapy, psychosurgery, sterilization and abortion.) The document also allows written specification of what types of treatment or the intensity of care an individual would desire if they were unable to make decisions for themselves. Decisions by the attorney-in-fact must be within the limits set by the individual, if any, when they complete the DPAHC.

The DPAHC is four (4) pages long, although not all sections must be completed. Health care providers, including emergency responders, respecting the decisions of the attorney-in-fact or written instructions in the DPAHC are provided immunity from criminal prosecution, civil liability, or professional disciplinary action.

Local EMS systems may use the DPAHC. Providers may be directed to respect the decisions made by an attorney-in-fact at the scene of an emergency when the patient is unable to make decisions for her/himself. Secondly, providers may respect directions they find written in the DPAHC regarding withholding or providing resuscitation. Finally, written information in the DPAHC gives health care providers direction as to the patient's wishes and may be valuable in assessing whether to proceed with resuscitation.

Another document is the "Declaration" found in the California Natural Death Act in Health and Safety Code Sections 7185-7194.5. This instrument is a declaration to physicians by adult patients directing the withholding or withdrawal of life sustaining procedures in a terminal condition or permanent unconscious state.

The directive only applies to incurable and irreversible conditions that "without the administration of life-sustaining treatment, will within reasonable medical judgment, result in death within a relatively short time." Two physicians must examine the patient and certify his/her condition in writing, the patient cannot be pregnant at the time, and the instrument must be witnessed by two individuals who are subject to certain limitations. Life-sustaining treatment includes any medical procedure or intervention, including hydration and nutrition, that serves only to prolong the process of dying or an irreversible coma or persistent vegetative state.

The Declaration should be viewed largely as a directive to the physician and other health care providers regarding the patient's wishes. It is not as suitable for use in prehospital care as standardized DNR directives, or even the DPAHC.

VII. BIBLIOGRAPHY

1. Miles SH, Crimmins TJ: Orders to Limit Emergency Treatment for an Ambulance Service in a Large Metropolitan Area. JAMA 1985; 254:525-527.

2. Haynes BE, Niemann JT: Letting Go: DNR Orders and Prehospital Care. JAMA 1985;254:532-533.

3. Miles SH: Advanced Directives to Limit Treatment: The Need for Portability. J Am Ger Soc 1987; 35:74-76.

4. American College of Emergency Physicians: Guidelines for Do-Not-Resuscitate Orders in the Prehospital Setting. Ann Emerg Med 1988; 17:1106-1108.

5. Minnesota Medical Association: "Emergency Medical Services Guidelines and Protocols to Limit Medical Treatments." Crimmins TJ (ed), Minneapolis 1985.

6. "Principles and Guidelines Concerning the Foregoing of Life-Sustaining Treatment for Adult Patients." Adopted by the Los Angeles County Bar Association, Los Angeles County Medical Association and Hospital Council of Southern California, January, 1986.

7. "Guidelines Regarding Withdrawal or Withholding of Life-Sustaining Procedure(s) in Long-Term Care Facilities." California State Department of Health Services, Sacramento, 1987. (Revised December, 1988).

8. County of San Diego Division of Emergency Medical Services. "Prehospital Determination of Death Policy", S-402, 1992. (See Appendix B)

9. 1990 Accreditation Manual tor Hospitals. Chicago, Ill: Joint Commission on Accreditation of Hospitals; 1989.

10. American Heart Association. Guidelines tor Cardiopulmonary Resuscitation and Emergency Cardiac Care. JAMA 1992: 268:2171-2302.

VIII. APPENDIX

Appendix A. California Emergency Medical Services Authority/California Medical Association statewide prehospital DNR Form

Appendix B. County of San Diego EMS Division Prehospital Do Not Resuscitate policy (Pre-Statewide Guidelines)

Appendix C. EMS Authority criteria for approving a medallion/bracelet

The Prehospital Do Not Resuscitate (DNR) Form has been developed by the California Emergency Medical Services Authority, in concert with the California Medical Association and emergency medical services (EMS) providers, for the purpose of instructing EMS personnel to forgo resuscitation attempts in the event of a patient's cardiopulmonary arrest. Resuscitative measures to be withheld include chest compressions, assisted ventilation, endotracheal intubation, defibrillation, and cardiotonic drugs. The form does not affect the provision of other emergency medical care, including palliative treatment for pain, dyspnea major hemorrhage, or other medical conditions.

This form applies only to resuscitation attempts by EMS providers in prehospital settings --i.e., in a patient's home, in a long-term care facility, during transport to or from a health care facility, and in other locations outside acute care hospitals. The form does not replace other written DNR orders that may be required pursuant to a long-term care facility's own policies and procedures governing CPR attempts by facility personnel. Patients should be advised that their prehospital DNR instruction may not be honored in other states or jurisdictions.

The Prehospital Do Not Resuscitate (DNR) Form must be signed by the patient or by an appropriate surrogate decision-maker if the patient is unable to make or communicate informed health care decisions. The surrogate should be the patient's legal representative (e.g., a Durable Power of Attorney for Health Care agent, a court-appointed conservator, a spouse or other family member) if one exists. The patient's physician must also sign the form, affirming that the patient/surrogate has given informed consent to the DNR instruction.

The white copy of the form should be retained by the patient. The completed form (or the approved wrist or neck medallion--see below) must be readily available to EMS personnel in order for the DNR instruction to be honored. Resuscitation attempts may be initiated until the form (or medallion) is presented and the identity of the patient is confirmed.

The goldenrod copy of the form should be retained by the physician and made part of the patient's permanent medical record.

The pink copy of the form may be used by the patient to order an optional wrist or neck medallion inscribed with the words "DO NOT RESUSCITATE-EMS." The Medic Alert Foundation (2323 Colorado Avenue, Turlock, CA 95381) is an EMS Authority-approved supplier of the medallions, which will be issued only upon receipt of a properly completed Prehospital Do Not Resuscitate (DNR) Form (together with an enrollment form and the appropriate fee). Although optional, use of a wrist or neck medallion facilitates prompt identification of the patient, avoids the problem of lost or misplaced forms, and is strongly encouraged.

If a decision is made to revoke the DNR instructions the patient's physician should be notified immediately and copies of the form should be destroyed, including any copies on file with the Medic Alert Foundation or other EMS Authority-approved supplier. Medallions and associated wallet cards should also be destroyed or returned to the supplier.

Questions about implementation of the Prehospital Do Not Resuscitate (DNR) Form should be directed to the local EMS agency.

An Advance Request to Limit the Scope of Emergency Medical Care

I, ______________________________________, request limited emergency care as herein described. (print patient's name)

I understand DNR means that if my heart stops beating or if I stop breathing, no medical procedure to restart breathing orheart functioning will be instituted.

I understand this decision will not prevent me from obtaining other emergency medical care by prehospital emergency medical care personnel and/or medical care directed by a physician prior to my death.

I understand I may revoke this directive at any time by destroying this form and removing any "DNR" medallions.

I give permission for this information to be given to the prehospital emergency care personnel, doctors, nurses or other health personnel as necessary to implement this directive.

I hereby agree to the "Do Not Resuscitate" (DNR) order.

__________________________________________________________________
Patient/Surrogate Signature & Date
__________________________________________________________________
Surrogate's Relationship to Patient

I affirm that this patient/surrogate is making an informed decision and that this directive is the expressed wish of the patient/surrogate. A copy of this form is in the patient's permanent medical record.

In the event of cardiac or respiratory arrest, no chest compressions, assisted ventilation, intubation, defibrillation, or cardiotonic medications are to be initiated.

__________________________________________________________________
Physician Signature

Date________________________

Print Name ______________________________________________________

Telephone____________________________________________________

Address___________________________________________________

THIS FORM WILL NOT BE ACCEPTED IF IT HAS BEEN AMENDED OR ALTERED IN ANY WAY

* To order this form, contact: California Medical Association
Publiciations Department
P.O. Box 7690
San Francisco, CA 94120-7690
or call (415) 882-5175

I. Authority: Health and Safety Code, Division 2.5, Section 1798.

II. Procedure:

A. When the patient is determined to be "obviously dead", resuscitation measures shall not be initiated.

1. The "obviously dead" are victims who, in addition to absence of respiration and cardiac activity, have suffered one or more of the following:

- Decapitation
- Evisceration of heart or brain
- Incineration
- Rigor Mortis
- Decomposition

2. The EMT shall describe the incident and victim's condition on the Prehospital Patient Record clearly stating the reasons that life support measures were not initiated.

B. All patients with absent vital signs who are not "obviously dead" shall be treated with resuscitative measures. Base Hospital Physician may make pronouncement of death by radio communication.

C. Except for signs of obvious death, if CPR has been initiated, BLS should be continued while contact is established with the Base Hospital.

1. Once the patient has been pronounced by the Base Hospital Physician, the EMT shall discontinue resuscitative efforts and s/he may contact the Medical Examiner.

2. The EMT shall describe the incident and the patient's condition on the Prehospital Patient Record, clearly stating the circumstances under which resuscitative efforts were terminated, to include the name of the Base Hospital Physician who pronounced the patient, and all available EKG monitoring documentation.

D. For patients with written, signed "Do Not Resuscitate" orders, follow procedures as established in San Diego County Division of EMS Policy S-414.

SUBJECT: DO NOT RESUSCITATE (DNR) Date: 9/1/92
__________________________________________________________________

I. Authority: Health and Safety Code, Division 2.5, Section 1798.

lI. Purpose: To establish criteria for Emergency Medical Technicians (all levels) in San Diego County to determine appropriateness of either:
A. withholding resuscitative measures, or,
B. obtaining Base Hospital Physician order for pronouncement of victims of cardiac arrest while in the prehospital setting.

III. Definition:

A. Emergency Medical Technician (EMT) shall apply to all EMT-I's, EMT/PS-D's, EMT-P's certified and/or accredited to function in San Diego County.

B. Do not resuscitate (DNR) means no chest compressions, no defibrillation, no assisted ventilation, no endotracheal intubation, and no cardiotonic drugs. The patient is to receive full treatment other than resuscitative measures (e.g., for airway obstruction, pain, dyspnea, major hemorrhage, etc.).

C. Absent vital signs: Absence of respirations and absence of carotid pulse.

D. DNR Medallion: metal or permanently imprinted insignia, worn by a patient, that has been manufactured distributed in accordance with County of San Diego Emergency Medical Services (EMS) requirements, is imprinted with the words "Do Not Resuscitate, EMS", and is approved by San Diego County EMS as a directive for EMS personnel to withhold or discontinue CPR on the wearer.

IV. Procedure:
A All patients with absent vital signs who are not "obviously dead" shall be treated with resuscitative measures, unless the EMT is presented with a written, signed order in the patient's medical record or a completed Prehospital DNR Request Form stating "Do not resuscitate", "No code", or "No CPR", or the patient is wearing a DNR Medallion.

1. An EMT may withhold or discontinue CPR in the following circumstances:

__________________________________________________________________
Approved:

__________________________ Administration_________________EMS Medical Director

SUBJECT: DO NOT RESUSCITATE (DNR)
Date: 9/1/92

a. the EMT sees a signed Prehospital DNR Request Form (original or copy) or
b. the EMT sees an approved DNR medallion.
c. During transports between medical/nursing facilities (between hospitals, nursing homes, clinics,
etc.) or if the patient is at a medical/nursing facility, the EMT may withhold or discontinue CPR if s/he sees
an original, valid, signed "DNR" order in the patient's medical record.
2. If the patient is conscious and states he/she wishes resuscitative measures, the DNR order must be ignored.
3. The presence of a DNR order, the physician's name signing the order and the date of the order is to be
documented on the Prehospital Patient Record (EMS Form).
4. If patient transport is undertaken, the DNR form (original or copy), DNR medallion, or a copy of the
valid DNR
order from the patient's medical record (during transports between medical/nursing facilities) is to be taken
with the patient.
5. DNR orders are to be honored during transport.
6. Contact the Base Hospital as needed.
B. If CPR has been initiated and a valid DNR order is present, CPR may be discontinued without Base Hospital Contact.

C. The manufacturers of DNR medallions must apply to the Division of EMS and agree to comply with the Division guidelines in order for their medallions to be recognized by San Diego County prehospital personnel. The Division of EMS will use the following criteria in evaluating and approving providers of DNR medallions that may be honored:
1. Provider must be a "not for profit" corporate entity with exclusive title to the design/logo on the medallion and exclusive control over the manufacturing and distribution of their medallion.

__________________________________________________________________
Approved:

___________________________Administration _____________________ EMS Medical Director

SAN DIEGO COUNTY DIVISION OF EMERGENCY MEDICAL SERVICES - No. S-414 POLICY/PROCEDURE/PROTOCOL - Page: 3 of 3

SUBJECT: DO NOT RESUSCITATE (DNR) Date: 9/1/92
__________________________________________________________________

2 Provider must maintain a 24 hour toll free telephone number for emergency information.
3. Provider must have existing widespread recognition, and a history of operation for at least five (5) years.
4. Providers must agree to manufacture and distribute medallions that have been engraved with the words "Do Not Resuscitate, EMS", ONLY after receiving a copy of a completed, approved DNR Request Form from an individual.
These medallions will also be imprinted with the toll free information telephone number and a unique patient identification number.

NOTE: In the event the patient expires en route, the following should be considered:

1. Unless specifically requested, the patient should not be returned to a private residence or skilled nursing facility.

2. Continue to the destination hospital or return to the originating hospital if time is not excessive.

3. If transport time would be excessive, divert to the closest hospital with a Basic Emergency Facility (BEF).

4. In remote areas, transporting agencies should make advance agreements with the office of the Medical Examiner for mutually acceptable rendezvous locations where the patient may be taken.

__________________________________________________________________
Approved:

_________________________ Administration ___________________ EMS Medical Director