The Coalition for Compassionate Care of California receives more than a few calls every month from providers, facilities, and members of the public with questions about advance directives and POLST. Though we don’t widely publicize this service, we’re happy to provide it. If nothing else, it helps us understand what people “out there” don’t understand – a lot of this stuff is complicated, and we welcome questions. What I am continually surprised by, though, is that some people seem not to understand “Do Not Resuscitate.”
Here's an example.
CCCC: Coalition for Compassionate Care of California, can I help you?
Caller: Yes, hi. I’m with [UNNAMED SNF]. One of our residents has a signed California DNR, but our facility policy is that if he arrests, we should start CPR until the EMTs get here, give them the DNR, and then they can decline to do CPR.
CCCC: [Stunned silence]
Caller: Is that ok?
Really and truly, I’m so glad they called, and kudos to the person who went to the trouble to ask because THAT IS NOT OK!!!!
We’re all familiar with the scenario of someone not having a DNR or POLST and getting CPR even when it’s unlikely to be helpful or even cause more harm, or even when the person is really already dead-dead-dead. If you don’t want CPR, we all say all the time, you must complete a pre-hospital DNR or check “No CPR” on your POLST and keep the form handy. (As an aside, a brilliant article, linked in the resources to this newsletter, by Sunita Puri in The New Yorker unpacks the “hidden harms of CPR,” and a CCCC webinar this month will present a print or digital decision aid to help patients make this and other tough treatment choices.)
First responders, let’s remember, are obliged to initiate all life-saving measures unless a DNR or POLST order is “apparent and immediately available.” Years ago I did some education programs in Colorado around the time of their medical aid in dying law going into effect. Part of the education was to encourage those utilizing the option to be sure to complete a pre-hospital DNR or POLST refusing CPR prior to ingesting the medication – just in case somebody panicked and called 9-1-1. (Not far-fetched; my teaching was based on a real-world case study.)
As I emphasized this point, a longtime fire chief attending the program concurred, “When we arrive, unless there’s a DNR or obvious signs of irrevocable death – such as lividity, rigor mortis, or decapitation – we have to proceed with life-saving efforts.” Alrighty then. I’d recommend documentation over decapitation, for the record.
I get it (sort of) if there’s no paperwork handy. But I do not get the concept that EVEN IN THE PRESENCE of a signed pre-hospital DNR, nursing facility staff would initiate CPR.
Again, I ask, What part of “Do Not Resuscitate” don’t we understand?
If the appropriate document is apparent and immediately available, there is NO defensible legal or ethical reason to ignore it, cave to please family members, worry about covering your liability, think you know better, or pass the buck on to the EMTs or the ED. PERIOD. EVER. IN ANY STATE.
I understand the messiness of real-world situations and have great empathy and respect for our first responders and other caring providers. But it’s time we all grew some, em, spine and followed the law. When people have carefully considered, discussed, and documented their wishes in legal instruments, they should have confidence that their wishes will be followed. We need to give them that confidence by backing them up.
“I’m sorry [Healthcare Agent, Miscellaneous Family Member, Co-Resident, Other Staff Member], Mr. X took the trouble to complete a pre-hospital DNR. I know this is hard for you, but that’s his voice talking, and our job is to listen to it.”
Can we do that?