DNR & CPAP
Question# 735
Hello! I had 2 questions where the answer was never quite clear:
1) Can CPAP be used on a pt who has a DNR? I heard that the answer is yes- if they were able to cooperate - but I wanted to make 100 percent sure.
2) If a patient is unconscious would we be allowed to BVM assist them (if they are breathing spontaneously). The stipulation in the DNR says no artificial ventilation so I would think no.
1) Can CPAP be used on a pt who has a DNR? I heard that the answer is yes- if they were able to cooperate - but I wanted to make 100 percent sure.
2) If a patient is unconscious would we be allowed to BVM assist them (if they are breathing spontaneously). The stipulation in the DNR says no artificial ventilation so I would think no.
Answer:
Thank you for your question, a question that is not easy to answer.
As paramedics, we’re often asked to apply black and white answers to grey situations, and this is a scenario that you’ve highlighted. When the patient is in cardiac or respiratory arrest, the answer is relatively easy – we honour the DNR and do not initiate treatment. When the patient is still alive, our job becomes more difficult.
Every situation is nuanced and unique, and it’s difficult to apply a blanket statement. Having said that, our blanket statement is that we should be approaching each situation with the lens of patient centered care, and use our clinical judgment. You can approach each one of these with a few things in mind:
Engage and include SDM's early into the resuscitation and obtain a sense of what the patient's goals of care/comfort measures are given the circumstances. A decision for DNR is often made in the context of cardiac arrest, in which the prognosis for many patients is typically poor. The patient may have different wishes in different circumstances, like a STEMI, for instance, where the treatment is different and the prognosis might be different. In the case of respiratory failure where the wishes are for comfort and the patient is in distress, positive pressure can be helpful for comfort and bridge to medication management of the dyspnea. This discussion needs to be had with the SDM. If the family member or SDM is in any way on the fence or unsure, they can always speak to the physician at the receiving facility in greater depth.
If there is any dispute, disagreement, or uncertainty amongst family or providers as to what the patient's wishes would be in this situation, resuscitation should be undertaken and you should always revert back to the BLS and ALS patient care standards.
Patching to one of the OMC physicians is always available and encouraged to discuss these infrequent clinical scenarios that can be difficult to navigate. Although typically time is of the essence, sometimes slowing down and including family and other health care providers in this discussion early on is ultimately what is best for the patient and their wishes. An OMC physician can help you and the patient/SDM understand the information relevant to the current decision and provide a sense of what the options are, and the pros and cons of each, so that an informed decision can be made by the patient/SDM.
We understand the challenges of these calls and understand these aren’t easy situations to navigate.
If you have any additional questions or concerns, please don't hesitate to reach out.
As paramedics, we’re often asked to apply black and white answers to grey situations, and this is a scenario that you’ve highlighted. When the patient is in cardiac or respiratory arrest, the answer is relatively easy – we honour the DNR and do not initiate treatment. When the patient is still alive, our job becomes more difficult.
Every situation is nuanced and unique, and it’s difficult to apply a blanket statement. Having said that, our blanket statement is that we should be approaching each situation with the lens of patient centered care, and use our clinical judgment. You can approach each one of these with a few things in mind:
Engage and include SDM's early into the resuscitation and obtain a sense of what the patient's goals of care/comfort measures are given the circumstances. A decision for DNR is often made in the context of cardiac arrest, in which the prognosis for many patients is typically poor. The patient may have different wishes in different circumstances, like a STEMI, for instance, where the treatment is different and the prognosis might be different. In the case of respiratory failure where the wishes are for comfort and the patient is in distress, positive pressure can be helpful for comfort and bridge to medication management of the dyspnea. This discussion needs to be had with the SDM. If the family member or SDM is in any way on the fence or unsure, they can always speak to the physician at the receiving facility in greater depth.
If there is any dispute, disagreement, or uncertainty amongst family or providers as to what the patient's wishes would be in this situation, resuscitation should be undertaken and you should always revert back to the BLS and ALS patient care standards.
Patching to one of the OMC physicians is always available and encouraged to discuss these infrequent clinical scenarios that can be difficult to navigate. Although typically time is of the essence, sometimes slowing down and including family and other health care providers in this discussion early on is ultimately what is best for the patient and their wishes. An OMC physician can help you and the patient/SDM understand the information relevant to the current decision and provide a sense of what the options are, and the pros and cons of each, so that an informed decision can be made by the patient/SDM.
We understand the challenges of these calls and understand these aren’t easy situations to navigate.
If you have any additional questions or concerns, please don't hesitate to reach out.
References
BLS PCS: Do Not Resuscitate Standard
ALS PCS: Continuous Positive Airway Pressure Medical Directive
ALS PCS: Continuous Positive Airway Pressure Medical Directive