# DNR Order



## BernDawg (11 Oct 2007)

Hey Gang:
     I have a question for the med community on the site.  I was asked, while instructing first aid, whether the MO (or CFMS) would honour a Do Not Resuscitate order for an individual specifically during a deployment.  I suggested that the medic on site wouldn't have time to bother with that and would treat all the cas in triage order as required.  So what's the scoop?
Thanks
Bern.


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## Old Ranger (11 Oct 2007)

Just from Civi Land in Ontario,
There needs to be proper documentation including a Doctor's signature.
And as Paramedics we have the right to not follow a DNR if we think something is not right (as in not Correct) about it.

Even with DNR tattooed on your chest, it won't stop the efforts.

It would probably be up to the Doctor on site to decide to honour a request that's in your file.
As for a Medic in a triage situation....life first, paperwork last.

Ben


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## RCR Grunt (11 Oct 2007)

On my TCCC course, we were instructed that if a patient o the battlefield has no pulse, is not breathing, and has holes in him, he is pri 4.  Thus the DNR order would be honored, but only becasue attempting to revive him in a situation like that would endanger the care giver.  There are, of course, exceptions to the rule.  I'm almost positive front line medics fly by this same rule, but don't quote me.


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## Donut (11 Oct 2007)

Writing from the Roll  Multinational Med Unit (1-08) in Wx on Ex Maple Guardian...the Assistant TF surgeon and I had a conversation on this the other day...he has urged all his troops to have both advanced directives and to be organ donors, as we desire.  An advanced directive is one term for a document that limits what life-saving measures you want in the event that you are severely injured...will you be fed through a tube?  Put on a ventilator?  Kept alive in a vegetative state? 

Now, I suspect if you come into our bays we're not going to pull your chart prior to beginning resuscitation...there's no time, but having an advanced directive in place would be honoured as far as possible, including an early end to resuscitative efforts if such was your wish, and if we knew about it.

I know that's a bit of a waffle on the question, but you may be one of 40 people streaming through our doors, and we can't check everyones file for a DNR, but we'll do what we can to accomodate what may be someones final wishes.

Talk about this with your next of kin.  Outline to them, in detail, what you do and don't want.  Give them a copy, duly signed and witnessed as per the laws of your home province, and have that person listed on your PEN and other NOK notification forms.

I hope this helps,

PMT


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## BernDawg (11 Oct 2007)

Thanks. That's pretty much what I figured.  The Meds would action a DNR as soon as they were aware of it and that would be after the initial trauma causing event and most likely some time after initial care at the FSH.  Now I have an answer I can pass on however with the caveat that it is not carved in stone as policy.


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## Blackadder1916 (11 Oct 2007)

It is not as simple as it sounds.  While there is some similarity among the different jurisdictions in Canada (10 provinces, 3 territories) with regards to advanced medical directives, it is not cut and dried.  I would recommend considerable research before making any statement to First Aid students concerning "DNR" orders and would suggest that such discussion (while interesting) is beyond the scope of a first aid course.  As a start, have a look at the following.

Living wills: FAQs
CBC News Online | March 22, 2005  much more at link


> *What is a "living will"?*
> A "living will" contains your written instructions about what level of medical treatment you want in the event that you are unable to express your wishes verbally. For instance, you may want all possible measures taken to keep you alive – or you could instruct that nothing be done to keep you alive.
> 
> You could also be very specific about what treatments you want, depending on the condition you are in. A living will would also specify whether you wanted to donate your organs when you die.
> ...


more at link


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## BernDawg (11 Oct 2007)

Of course DNRs are not part of our standard curriculum however I was asked by a student if the CF would honour one and At the very least I now have an anecdotal response if I am ever asked the question again.  It's more for my own curiosity really.


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## Armymedic (11 Oct 2007)

BernDawg said:
			
		

> whether the MO (or CFMS) would honour a Do Not Resuscitate order for an individual specifically during a deployment.  I suggested that the medic on site wouldn't have time to bother with that and would treat all the cas in triage order as required.



Officially, of course the medical staff would honour a DNR once they became aware of it. But:

1. If you are deployed why would you have a DNR?
2. If you are of military service and have no health problems, why do you have a DNR?
3. If you require/have a DNR, why are you deployed?
4. Your med files are not deployed with you so unless it is one the pieces of paper Medical staff take over states it in bold letters, then you're shit out of luck.

One of those totally hypothetical First Aid questions that a MO would say that is not probable nor possible due to regulations.

And from a medic's point of view (me personally)...you wanna have a DNR, go play with someone else. I only lose the ones I have no chance of saving. I WILL work you until I am relieved, because while you don't care cause you are dead, me and your buddies still have to live.


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## BernDawg (12 Oct 2007)

Well yeah I did have those thoughts as well but when you're working on an air base you have to be kinda PC in your responses.


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## Armymedic (12 Oct 2007)

BernDawg said:
			
		

> Well yeah I did have those thoughts as well but when you're working on an air base you have to be kinda PC in your responses.



I understand. But now armed with some more info, you may tell that person that thier hypothetical situation is "while possible, not likely given current medical regulations".


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## TCBF (12 Oct 2007)

Is this thread missing a post, by any chance?


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## old medic (12 Oct 2007)

TCBF, It looks complete. 
Excellent answers from everyone too.

Just to amplify a few points everyone else already hit;

The Military Health system is a separate system from the provinces.

Some provinces have various policy and legislation on DNR's.

BergDawg, for the specific question of 


> " whether the MO (or CFMS) would honour a Do Not Resuscitate order for an individual specifically "



To have a DNR in the military, there would need to be a policy
on DNR orders, not someone else's policy.  Some sort of legal process 
has to validate that "do not resuscitate" is the most current wish of the patient. 

The advanced directive is the answer. It's the way for the member to express
their wishes for care (care plan). 

Even *IF* an advanced directive was so restrictive as to be similar to "don't touch me", the med docs
don't follow you around, and field triage doesn't include a check of the 2034
or electronic medical records. 

The various points about life first, start resuscitation are right on the money.
Civy side, they get worked until that signed DNR order is produced. We'd look foolish
if we did nothing while someone checked around.  

Here's a catch for you. 
In Ontario, we currently  have DNR validity forms for transferring patients between medical facilities only. 
They do not apply to trauma and emergencies. There are changes coming to 
allow paramedics and firefighters to honour DNR's in other situations. Here is a
link to an Ontario Fire Marshall Communique on the subject:

http://www.ofm.gov.on.ca/english/publications/Communiques/2007/2007-21.asp

There is a line in it -  





> If the patient is subsequently transported to a health care facility or other care setting, the care providers at the facility or other care setting will decide whether they will honour the form.



ie. even if the Paramedics in Ontario honour the DNR, it doesn't mean the next level
of care has too. A re-assessment is allowed.


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## BernDawg (12 Oct 2007)

Thanks for the responses folks.  Now I have yet another tool in the box. I hate being stuck for an answer.


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## COBRA-6 (6 Nov 2007)

A follow up question as I am trying to tie together a few related admin items like will, living will, power of attorney, SISIP etc... 

Where should any advanced directive(s) or "living will" be kept. I am planning to include one with my will but that won't help if they don't look at a will kept by a civilian attorney until after death has occurred. Should a copy be placed in the med docs? With the NOK? Both?

Cheers,
C-6


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## Donut (6 Nov 2007)

C-6,

I'm planning to place one just about everywhere...my NOK know, my attorney will have a copy, my CoC (the TF surg and his deputy) will all be informed, my unit padre will be info'd...the more copies there are the better in my opinion.  Hand a copy over to med records at your home CDU, tell every one who might have standing before a court.

Canada's not quite as litigious as our cousins to the south, but having seen some of the circuses that have gone on in the courts, I don't plan to have people argueing over my feeding tube.

Perhaps I'm being overly cautious on this, but it's not something I'm taking lightly.

DF


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## medic65726 (6 Nov 2007)

I've been reading a book on "Bioethics in Armed Conlict" and while rather dry, does raise some rather interesting points in this sort of regard.
Generally peopel have the right to consent to or refuse treatment, but what about while serving in the CF?
Can you refuse mandatory pre-deployment vaccinations? If you cannot refuse, then can you refuse potenitally life saving treatment?
Your obligation is to remain fit for service, so in the same way that a self-inflicted injury that makes you unfit may be chargable, what about refusing treatment?
Just food for thought..............


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## Armymedic (6 Nov 2007)

Medic65726 said:
			
		

> Generally peopel have the right to consent to or refuse treatment, but what about while serving in the CF?


You still have the right to refuse any treatment while employed in the CF



> Can you refuse mandatory pre-deployment vaccinations? If you cannot refuse, then can you refuse potentially life saving treatment?


 You can, but then you will be ordered to, probably charged and taken off the tour. But if you steadfastly refuse, med pers will not give you the shot. As for the second part...nice hypothetical, and you'd be an idiot. After, if we saved you, you would be referred to psych. We will not recognize suicide atttempts.



> Your obligation is to remain fit for service, so in the same way that a self-inflicted injury that makes you unfit may be chargable, what about refusing treatment?


Your choice...every choice has consequences. Refusing tmt may result in your dismissal as you are no longer fit for service.


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## medic65726 (6 Nov 2007)

Yes, but the premise of consent in all aspects of Canadian Law is that it is informed, and given freely, without coercsion or threat.
There would be no doubt by anyone that consent to sex would not be valid if there were threats associated with the giving of consent, so how valid is ones consent to any treatment if there is the threat of release or charges if one does not consent?


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## ModlrMike (7 Nov 2007)

Medic65726 said:
			
		

> Yes, but the premise of consent in all aspects of Canadian Law is that it is informed, and given freely, without coercion or threat.
> There would be no doubt by anyone that consent to sex would not be valid if there were threats associated with the giving of consent, so how valid is ones consent to any treatment if there is the threat of release or charges if one does not consent?



Because the release would be an administrative action, not a disciplinary one. For example, if you refused immunization, you would quickly DAG red as undeployable. The result would most probably be release.


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## medicineman (7 Nov 2007)

Last I looked, it's still on the NDA (and best of my knowledge, has been held up in court) that it is a lawful order to submit to immunization.  It falls under the aspect of greater good - not just for yourself, but anyone else you could spread the disease to in your unit, and also to ensure that operational strength is maintained in theatre.  For instance, a run of influenza through a FOB could knock a whole load of people out for a week or longer - kinda makes it hard to carry out the mission.  So, the release could in fact be potentially a disciplinary one.

MM


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