One common — but complex — medical-legal question that arises in EMS is whether there are circumstances when it’s legally and ethically permissible not to attempt resuscitation on a cardiac arrest patient. Certainly, the decision not to resuscitate has irrevocable consequences for the patient, and it should be made only when all legal and ethical considerations are strictly satisfied.
The first issue an EMS provider must consider is their state law. Some states’ “do not resuscitate” (DNR) laws stipulate that resuscitation can be withheld or discontinued only in very specific circumstances, for example, when the EMS provider confirms that a valid “DNR order” such as in the form of a bracelet, necklace, form or card is present. Other state laws dictate that an online EMS physician can order a DNR in particular circumstances. In addition to consulting your state law, be aware that your state and/or local EMS oversight agency may have regulations, policies or protocols that address DNR issues.
There are also cases where, both legally and ethically (and subject to your state’s laws, regulations and protocols), resuscitation isn t clinically indicated. Generally, these include such cases as decapitation, rigor mortis (except in cases of profound hypothermia), dependent lividity, decomposition, and obvious mortal wounds when survival is not possible.
A third category of potential DNR patients may include the terminally ill, such as patients suffering from advanced, end-stage or untreatable cancer or other terminal diseases. In these cases, patients and/or their legal decision makers should avail themselves of the formal EMS DNR process in their state (which exists in most states) so that they can obtain the proper EMS DNR identification. However, in cases where no such DNR order exists, the EMS provider should provide full resuscitative measures, unless the patient is legally pronounced dead (by a person authorized to do so in that state) or unless a qualified EMS physician, who is permitted by state law to give such orders to EMS personnel, specifically gives a DNR order.
In cases that do not meet these criteria, EMS providers should initiate full resuscitative interventions for cardiac arrest patients. A DNR decision is irrevocable and should be made only when all legal and ethical factors have been taken into account.
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