Dnr

[M&M]

How is this with you guys and gals. If you get called to an attempted suicide and the pt has a DNR, do you run the code or not. Our attorney is supposed to call me back on it (in his own sweet time). Personnally I think we should as the pt is obviously not in the right state of mind and has just commited a crime. With us here in the field, if a pt has a DNR and the family says run the code, we're supposed to do it then let the doc handle it at ER. And obviously, if they can't show legal proof then we run it anyhow.

How do you do it in your area? Just wondering and thanks ahead of time.:respect:

[Nate]

They can always turn the vent. off.

[WELLAGEDEMT]

In our area, DNR means that if a patient has expired, we are not supposed to use any "heroic"attempts to try to bring that patient back. If we witness the lack of breathing, we can ventilate, if we witness the cardiac arrest we can use CPR. If the family requests, we can intervene, but if we have any questions concerning our response, we can call for medical direction.

[IAMedic]

Ahh, I haven't had a good DNR question in a long time. Unfortunately, you didn't give much information regarding this scenario.

Were they coding, did you have a signed DNR in front of you and/or was family around. A little more information would help me get a better picture of what I would have done.

[EMSsquirrel]

I believe our protocol is, "work 'em." After all... when someone commits suicide, they want to die, right? Isn't wanting to die like wanting to not be resuscitated? So shouldn't ALL suicides be considered DNRs?

But I'll dig out Ye Olde Maryland Medical Protocols, Spells, Elixirs and Concoctions for Health tomorrow and see what the fine minds downtown have to say about this.

- Greg

[smurfe]

Depends on the method of choice. If they blow their brains out, no, if they hang themselves and it is fresh kill, I might consider it but still probably not.

My motto always has been if you truly want to die, I am not going to step in your way to stop it. Smurfe's philosophy of EMS has always been help those that want your help. If they don;t want it, I am not going to butt in and make them take it.

Smurfe:beer:

[volparamedic]

I've ran into problems once....

family called 911 stated that family member had OD and was gone. When we got there she presented the DNR form. I had been at the residence before and knew that the guy was disabled severely enough that he couldn't take the pills she claimed he took. Of course he was breathing 6 times a minute, brady and pin point pupils. A medicine that had a lot missing of course was an opiate. I explained to her that it is illegal to commit suicide and he wasn't dead...yet. He can around nicely with narcan and due to transport time had to be rebolused with resp depression again. She never tried that again when the police got involved and explained the situation.

[smurfe]

I've ran into problems once....

family called 911 stated that family member had OD and was gone. When we got there she presented the DNR form. I had been at the residence before and knew that the guy was disabled severely enough that he couldn't take the pills she claimed he took. Of course he was breathing 6 times a minute, brady and pin point pupils. A medicine that had a lot missing of course was an opiate. I explained to her that it is illegal to commit suicide and he wasn't dead...yet. He can around nicely with narcan and due to transport time had to be rebolused with resp depression again. She never tried that again when the police got involved and explained the situation.

This situation would not fall under a DNR. It would a Living Will but most states prohibit Pre-Hospital from honoring Living Wills. A DNR is only active if a patient is pulseless AND apenic. Honoring a DNR in this situation is negligence.

I to have always heard the saying that is illegal to try to kill yourself. In the 3 states I have lived in and worked in, I have yet been able to get a cop to produce me the statutes that actually say it is against the law to commit suicide. :bang: I have heard numerous cops make the statements but in 25 years I have yet seen one "charged" with this offense. :mad:

Smurfe :beer:

[RyanEMVFD]

Under our protocols and I think Texas law, DNR becomes invalid if there is a suicide attempt, patient is pregnant and a few other things.

[WELLAGEDEMT]

If suicide is illegal, what are the penalties? Are you gonna' get the chair or lethal injection or maybe hanged? Kinda ironic that the legal way is more effective than the "don't try this at home" methods. ;)

[btroutm]

If suicide is illegal, what are the penalties? Are you gonna' get the chair or lethal injection or maybe hanged? ;)
Well, I think you'd really have to take the circumstances into account...Was it pre-meditated or did it occur in the heat of the moment? :)

Back on topic... I don't know if there are any state regulations in Illinois that cover this issue (although we do have these great new DNR forms that are actually correctly filled out!) and our protocols don't mention it. So, if I had to make the call in the field, I would work them (if it is an obvious attempted suicide) until medical control tells me to stop.

On a side note, anyone know if attempting suicide is illegal? If it is, I would hope there isn't a punishment, but a requirement to seek medical treatment.

[M&M]

As far as what is done when someone attempts suicide here in Nebraska. If someone makes an attempt or talks of it, then law enforcement comes in and has them EPC'd (emergency protective custody). My main job is working at the psych unit at our hospital and we get these people all of the time. There is no punishment per say. What we do is try to get them the help they need, whether it be medications or councelling. I thought I was ready for anything until I started working there. You'd be surprised at all of the people out there with some kind of mental illness. They say one out of every four people has some sort of mental illness, majority of which is perfectly harmless. Be carefull out there, I found out the hard way that if someone is suicidal then they are also homicidal (what do they have to lose).

By the way, our attorney got back to me (finally). If it is suspicious or obvious suicide, we run the code and have law enforcement meet us there to EPC.

Thanks to everybody for your input. It was very interesting. Have fun out there and be safe.

[WELLAGEDEMT]

My question about penalties was a jab at the legal system. I certainly think that some form of intervention, medical or counciling, is the best route. The patient has failed, again. Most of the suicides are failure related, failure with family, job, school or relationships. To consider further penalty for the patient is just adding to the list with the attempt being the latest failure. Just give them some peace!!!!!

[rory_el]

Wellaged,
I think a better more pruductly way to view these 'failures" as an inablility to adequately cope with life stressors. The penality is, you're given psych help once your immediate medical needs are meet. Without that penality they wouldn't get any help. Ryan nailed it. Always work suicides unless their obviously dead per your protocols

[yankeemt]

I think the only crime in any of the situations we face where a DNR is in question is not doing what we all were oathed to do and thats care for pt's
(my personal belief is the only counseling the need is how to hit the right artery there are to many people out there that want help for out time to be monopolized by those that don't care) I'd like to think you can't be faulted for doing what you were trained to do as long as you are actions are of good intent, within your scope.

[sfd178]

In Alabama, if the family cannot produce the State Of Alabama DNR form or the patient is not wearing a State EMS DNR bracelet (a blue & white bracelet with appropriate lettering), we have to work the patient if certain conditions apply. Which would include 1. CPR already in progress, 2. a witnessed arrest, 3. confirmed V-tach or V-fib, or 4. if the family says to work the patient.

Here is the link to the State of Alabama EMS Rules.

http://www.adph.org/ems/emsrules.pdf

[mcaldwell]

I actually had a family come to the local resort last summer for a couple of weeks, and the first thing they did was contact the FD and Security Dept to let them know that thier Grandmother had a DNR order.

That freaked me out a little, and I fully expected to get a call for that one while they were here. I figured they either had this whole thing planned out (i.e. come die in a nice place), or were just a little too eager to see Grandma kick off so they could get the inheritance.
:o

As for our policy, show the written order, or we work the pt. For the suicide, I think I would ignore the order, but thankfully I haven't faced it yet.

[Medicmaster]

I'm sure that laws vary from state to state, but...

Suicide has been deemed "against the law" essentially as a technicality. You don't pay a fine, or face prison time, but it allows a court ordered committal to a psychiatric facility for a determined amount of time, usually not less than 48 hours in the event of a suicide attempt, or suicidal/homicidal ideation.

As far as a DNR, here in Iowa atleast, the statute does not talk about suicide. However, I once had a case where an 82 year old overdosed on Insulin, and took a few handfuls of benzodiazepines. She was alive on arrival at the scene, but required ventilatory assistance, and IV D50 to correct her blood sugar of 6 mg/dL (which by the way didn't work...for long anyways). One of her family members presented us with a DNR and explained that if her heart stopped, we were not to do anything further.

We transported and arrived at the hospital with her still alive. I explained to the ER doctor what the family had said, and he explained that because she had attempted suicide, she had to be RSI'd and intubated, and subsequently tranferred to an ICU 60 miles away.

I've spoken with several doctors since, and the general concensus has been to work it if you suspect suicide even with a DNR unless obvious signs of death are present.