Verbal DNR from Patient

The ALS PCS v 5.4 Preamble on page 6 informs paramedics that ...

"If a patient is incapable of consenting to a proposed treatment plan, and the paramedic is aware or is made aware that the person has a prior capable wish with respect to the proposed treatment, they must respect that wish (for example, if the person does not wish to be resuscitated)."

This statement is in alignment with the requirements imposed on healthcare providers in the Healthcare Consent Act as well as previous positions taken by the RPPEO and as articulated in Patient Consent & Do Not Resuscitate by Dr. Mark Froats.

In order to address the discrepancy between the ALS PCS position as described above and the requirement in the BLS PCS Do Not Resuscitate Standard that paramedics ONLY accept the MOH DNR Confirmation Form the RPPEO has provided direction to paramedics on how to handle verbal DNRs from an SDM in CLI 230 Management of Death in the Prehospital Setting (RPPEO Policies).

In the circumstance you are describing where the patient is requesting (potentially for the first time) not to be resuscitated and then does in fact go into cardiac arrest there are several complicating factors to be considered.

The first is whether or not the patient was able to consent. Did they have capacity? The ALS PCS 5.4 lays out the elements of consent on page 5.

"The elements required for consent to treatment are:

a) consent must be given by a person who is capable of giving consent with
respect to the treatment plan;
b) consent must relate to the treatment plan;
c) consent must be informed;
d) consent must be given voluntarily; and
e) consent must not be obtained through misrepresentation or fraud."

The ALS PCS v 5.4 further details the elements of informed consent (point c. above) ... "Consent to the treatment plan is informed if, before it is given by the person, he or she has:

a) received the following information that a reasonable person in the same
circumstances would require in order to make a decision about the treatment
plan:

i. the nature of the treatment;
ii. the expected benefits of the treatment;
iii. the material risks of the treatment;
iv. the material side effects of the treatment;
v. alternative courses of action;
vi. the likely consequences of not having the treatment; and
b) received responses to his or her requests for additional information about those
matters"

Capacity and consent conversations at the best of times are nuanced, in circumstances surrounding the decision to obtain a DNR these conversations are especially so and typically take place in calm and controlled environments. Furthermore, it would be quite difficult to establish that a patient had capacity and met all the elements described above to consent to a DNR while in state of critical illness in the prehospital environment.

The Base Hospital Physician group has some recommendations to consider in the circumstance you are describing.

• Recomendations
  • If patient has capacity (as per laid out criteria) and at risk of critical illness (deterioration), the paramedic can verbally accept the patient’s own “verbal DNR”
  • If the patient is deemed to be dead (VSA, naturally occurring / absence of trauma or foul play) and there is an SDM expressing verbal DNR on behalf of the patient:
    • Confirm VSA and rhythm on limb leads
    • Confirm natural occurrence / absence of foul play
    • Patch call base hospital as soon as possible while resuming resuscitation efforts.
  • We acknowledge that there may be some significant moral dilemma associated with these scenarios and our paramedic colleagues should continue to reach out to their support systems and flag specific scenarios should they arise.