MIEMSS Changes EMS Policy for Patients with DNR in Place; Response teams providing restorative treatment cannot insert breathing tubes
August 6, 2010
This is a periodic communication from attorneys in Ober|Kaler's Long Term Care Group designed to update our clients on current legal developments relating to the long term care provider community.
On July 1, 2010, the Maryland Institute for Emergency Medical Services Systems (MIEMSS) changed its policy for Emergency Medical Services (EMS) personnel responding to a scene. Under its historical policy, EMS teams would, as part of restorative care, intubate a patient with difficulty breathing. Under the new policy, if, the patient has a MIEMSS form indicating the patient does not want CPR and has a Do Not Resuscitate (DNR) MIEMSS form in place but does want restorative care from EMS prior to any cardiac arrest, EMS teams will administer restorative care, but will not put in a breathing tube. In other words, EMS teams will continue to initiate life-sustaining treatment, but where there is a MIEMSS DNR and Medical Care Order Form, that form will take priority.
The form states:
This form is a physician's or nurse practitioner's order under which EMS personnel will not attempt resuscitation when the patient named below is in cardiac arrest (no palpable pulse) or respiratory arrest (no spontaneous breathing). This form also instructs EMS personnel on interventions before arrest. EMS personnel who see this order or a copy of it or physical evidence of it (the attached bracelet or Medic Alert bracelet or necklace with DNR emblem) are to provide care in accordance with this order and applicable Maryland Medical Protocols for EMS Providers. Unless a later physician's or nurse practitioner's order relating to resuscitation has been issued, or unless the health care provider reasonably believes the EMS/DNR order has been revoked, every health care provider and facility is directed by law to follow the EMS/DNR order by not resuscitating a patient who lacks a pulse or spontaneous respirations.
MIEMSS changed its Maryland Medical Protocols for EMS Providers concerning the selection of "Option A" (Maximum Efforts to Prevent Cardiac/Respiratory Arrest) on the EMS/DNR Form. (Under "Option B," only supportive care is provided and a DNR is in place). Under the change in policy, individuals selecting Option A will receive restorative care but, in addition to not using CPR in a cardiac arrest, the EMS team will not intubate the patient.
MIEMSS will be issuing an updated form to effectuate this change. The change will not affect EMS response to the "old" form — that is, patients who have selected Option A on the "old" form will receive oral/nasal intubation as part of their care if indicated.
Attached is a memorandum [PDF] issued by Dr. Richard Alcorta, State EMS Medical Director, explaining the distinction between the "old" EMS/DNR-A (with the delivery of intubation if indicated) vs. the "new" EMS/DNR-A (DNI) (Do Not Intubate) forms. Dr. Alcorta notes that this change is the result of patients, patient advocates and physicians requesting the removal of intubation from Option A as it is believed that many patients with treatable diseases select Option B (Supportive Care Prior to Cardiac Arrest) to avoid the risk of ever being intubated.
Once the new form is issued, according to MIEMSS, health care facilities and practitioners should consider having a conversation with their patients regarding their EMS/DNR forms to consider whether the selection on the form is consistent with the patient's wishes and whether a new form should be completed. As part of this discussion, long-term care facilities should consider whether the patient's selection on the EMS/DNR Form is consistent with the patient's wishes reflected on his or her Instructions on Current Life-Sustaining Treatment Options (LST Options) Form. Notably, Part C of the LST Options Form allows a patient or authorized decision maker to express wishes regarding CPR and Part D allows a patient or authorized decision maker to express wishes regarding artificial ventilation. Patients that indicate "Yes" to artificial intubation may need to reconsider asking for a DNR since if there is a DNR that person will not be able to use the "new" EMS/DNR form, as under both options nasal or oral intubation is not allowed. Such patients could, however, continue to use the "old" form if they already have one in place, which will be honored by EMS providers who will provide nasal and oral intubation under Option A when appropriate.