Are on-site paramedics required to follow living will or do not resuscitate orders?

For families facing the impending death of a loved one, few topics trigger more anguish than a do not resuscitate order (DNR), an advance directive requesting not to have cardiopulmonary resuscitation (CPR) done if the heart stops or breathing ceases. The subject can be so painful that relatives and doctors wait too long, until the patient's mental capacity wanes and the tough decision is left to family members. If you or someone in your family has an emergency and paramedics arrive on the scene after a 911 call, the presumption on their part is that you want to be saved from death until they receive definitive information to the contrary.

While the rules vary from state to state, and even from hospital to hospital, generally, emergency personnel will notfollow directives for DNR in a living will, even if it is waved in front of their faces. They are not physicians and their job is to stabilize the patient and transport him or her to a hospital where decisions about treatment can be made. With proof of a physician-signed DNR, however, they will usually comply and not perform CPR.

The reluctance among doctors and family members to initiate talks about this issue with their loved ones runs so deep that thirty plus years after DNR orders were introduced, their use still remains spotty. Some states, however, have recently adopted a new kind of form that could make the process easier. The order is signed by a doctor or nurse practitioner, and a copy is carried by the patient so that his or her wishes may be honored at hospitals, nursing homes and by emergency medical personnel.

Note that even if there is a DNR, if it is not filled out completely or signed properly, the paramedics will generally not abide by it. As difficult as it may be to discuss and carry out, if you or your elderly or sick family member does not want to be resuscitated, it is very important to make sure a DNR is prepared completely, signed by the individual and their physician, and hung up prominently at home. Interestingly, less than 5 % of chronically ill or elderly patients revived by CPR live long enough to be discharged from the hospital, and the fraction that survive are a far weaker version of themselves, often neurologically impaired. CPR frequently breaks fragile bones and may cause internal bleeding. (Boston Globe, December 7, 2007)

It is important to understand that a DNR order only indicates that CPR should be withheld in the event of cardiac or respiratory arrest. Emergency medical providers must ensure that all patients receive thorough and proper assessments and that, short of CPR, those treatment modalities which correlate with the findings of those assessments and accepted standards of care are carried out.

Don’t wait until it is too late for you or your loved one to make this important decision and complete the necessary forms. Get them signed by a physician or medical practitioner. Especially if one of you is elderly or seriously ill, it is imperative that family members and medical personnel have the documents they need to carry out your wishes.