PCTH - DNR & Patient Management

Question 1

True or false. All patients will be deemed to be viable and will be treated as living persons and provided with the care & transportation required unless they are Deceased Patients (as defined in the Deceased Patients Standard).

Answer 1

True

Question 2

True or False. When you tell dispatch “arrive scene” you MUST completion some form of documentation.

Answer 2

True

Question 3

If a bystander called 911 for a patient without the patient knowing and upon paramedics’ arrival, the patient claims they “did not want to go to the hospital in the first place”, do they still need to sign a refusal of service?

Answer 3

Yes, technically anyone who someone calls 911 for is considered a patient and needs to sign a refusal if they don’t want to go.

Question 4

A “deceased patient” means a patient who is (5):

Answer 4

1) obviously dead
2) the subject of a medical certficate of death, presented to the paramedic crew, in the form that is prescribed by the Vital Statistics Act and that appears on its face to be completed and signed in accordance with that Act
3) VSA and is the subject of a DNR confirmation form
4) VSA and is subject of a TOR order give by a BHP
5) VSA and the subject of a Withhold Resuscitation Order given by a BHP

Question 5

What does “obvious death” mean (excluding criteria for VSA patients), as per the Deceased Patient Standard?

Answer 5

means death has occurred if gross signs of death are obvious, including by reason of:

1) Decapitation
2) Transection
3) Visible decomposition
4) Putrefaction

Question 6

In VSA patients, what does “obvious death” mean, as per the Decreased Patient Standard?

Answer 6

1) a grossly charred body
2) an open head/torso wound with gross outpouring of cranial or visceral contents
3) gross rigor mortis (limbs and/or body totally stiff, posturing of limbs and/or body)
4) dependent lividity (fixed, non-blanching purple or black discolouration of skin in dependent area of body)

Question 7

Define Termination of Resuscitation (TOR) order

Answer 7

an order given by a BHP to a paramedic to stop resuscitation efforts

Question 8

Define unexpected death

Answer 8

a death that was not imminently anticipated (eg. traumatic deaths, deaths related to the environment, accidental deaths, and apparently natural deaths that are sudden and unexpected)

Question 9

Define expected death

Answer 9

a death that is imminently anticipated generally as a result of a progressive end stage terminal illness

Question 10

Define Withhold Resuscitation Order

Answer 10

An order given by a BHP to a paramedic to not initiate resuscitation measures

Question 11

Define Palliative Care Team

Answer 11

A team of HCPs who provide palliative care to a terminally ill patient

Question 12

Define Responsible Person

Answer 12

an adult who, in the reasonable belief of the paramedic, is capable to remain with the deceased patient and assume responsibility for the deceased patient

Question 13

What are the 10 steps that a paramedic shall follow, as per patient management standard?

Answer 13

1) if the patient is VSA and meets “obvious death” criteria as per Deceased Patient Standard, follow procedures as outlined in that standard
2) if patient has MOH DNR confirmation form, refer to DNR Standard
3) perform appropriate critical interventions to establish/improve and maintain airway patency, ventilation and circulation (covered in another flashcard)
4) administed oxygen therapy as per Oxygen Therapy Standard
5) initiate management of other life-, limb- and/or function-threatening conditions as outlined in other sections of the Standards and the ALS PCS
6) position/re-position patient in order to support, protect, improve and/or promote: C-spine alignment, airway patency, breathing, venous return/perfusion, extremity injury, and patient comfort
7) if patient is stable, initiate management on-scene for non-critical conditions
8) continually monitor patient and provide ax and management as per Standards
9) give patient nothing by mouth unless indicated by the Standards or ALS PCS
10) ensure patient maintains a comfortable temperature, or as required by the Standards

Question 14

Section (3) of Patient Management Standard indicates that the paramedic shall “perform appropriate critical interventions to establish/improve and maintain airway patency, ventilation and circulation, which include what (5)?

Answer 14

1) protecting C-spine if C-spine precautions are indicated by SMR Standard
2) initiating CPR as per current Heart and Stroke Foundation of Canada Guidelines and as per Cardiac Arrest Standards, if the patient is VSA (perform appropriate cardiac arrest medical directives as outlined in ALS PCS)
3) clearing airway obstructions as per Airway Obstruction Standard, with attention to suctioning of saliva, blood and vomit where necessary
4) ventilating or assisting ventilations as per Respiratory Failure Standard or Shortness of Breath Standard
5) controlling trauma-related external hemorrhage as per Soft Tissue Injuries Standard, or as specified in other standards for both trauma and non-trauma related conditions

Question 15

Ambulance Communication Centers are ________ (provincially/munipality/federally) funded.

Answer 15

provincially

Question 16

What do Ambulance Communication Centres use for dispatching priorities?

Answer 16

Dispatch Priority Card Index - directs the Call Taker to ask precise questions that pertain to specific emergencies

Question 17

Medical communication officers will act as both _______ or _________.

Answer 17

call takers; dispatchers

Question 18

What does Code 1 mean?

Answer 18

“deferrable” - a routine call that may be delayed without being detrimental to the patient (ex. a non-scheduled transfer; a minor injury)

Question 19

What does Code 2 mean?

Answer 19

“scheduled” - a call which must be done at a specific time (for example, due to special tx/dx facilities being available only for a certain period of time)

Other examples:

• inter-hospital transfers for MRI
• a scheduled meet with air ambulance

Question 20

What does Code 3 mean?

Answer 20

“prompt” - a call that should be performed without delay (ex. serious injury/illness such as a stable fracture)

Question 21

What does Code 4 mean?

Answer 21

“urgent” - a call that must be performed immediately where the patient’s life or limb may be at risk
- ex. VSA, unconscious head injury

Question 22

What does Code 7 mean?

Answer 22

Cancelled

Question 23

What does Code 8 mean?

Answer 23

“Stand-by” - a call where an ambulance is dispatched to a pre-determined location in order to stand-by for further call re-assignment

• ex. covering an area that is not typically yours

Question 24

What does Code 9 mean?

Answer 24

“maintenance” - a call where the vehicle is out of service for maintenance

Question 25

When did the DNR policy first appear? Broadly describe what about the policy changed over time.

Answer 25

• first appeared in 1999
• there were initial limitations (many caveats for honouring DNRs; could only honour DNR if patient was coming out of a healthcare facility
• now there are new directives that allow for greater flexibility

Question 26

Define: Do Not Resuscitate Oorder

Answer 26

The existence of a current plan of treatment that

(1) reflects a patient’s expressed wish when capable, or the consent of a SDM when patient is incapable, that CPR not be included in the treatment plan; or
(2) is valid when it is a physician’s current opinion that CPR will almost certainly not benefit a patient and it is therefore not part of the plan of treatment

Question 27

Define: Cardiopulmonary Resuscitation (CPR)

Answer 27

An immediate application of life-saving measures to a person who has suffered a sudden respiratory or cardiorespiratory arrest. The measures include the critical interventions described within both basic and advanced cardiac life support.

Question 28

If a physician signs a DNR form, what is it called?

Answer 28

DNR Confirmation Form

Question 29

Besides a physician, what other HCPs can sign a DNR form?

Answer 29

1) RN
2) RN in extended class (R.N. (EC))
3) RPN

Question 30

When a nurse signs a DNR form, what is it called? If it differs from a DNR, how so?

Answer 30

Validity form - meaning somewhere in the notes/documents there is an actual DNR order

Question 31

What are the components of a DNR Confirmation Form?

Answer 31

1) Unique 7-digit serial number
2) Identification box - states purpose of form and identifies the patient
3) Point 1: definition of DNR and treatment prior to arrival
4) Point 2: definition of pallative care
5) Reason for DNR (i.e. patient’s wishes or physician’s opinion)
6) Level of provider name and signature

Question 32

As per the DNR Confirmation Form, what is the definition of DNR And CPR?

Answer 32

DNR: means a paramedic (according to scope of practice) or firefighter (according to skill level) will not initiate basic or advanced CPR such as:

1) chest compressions
2) defibrillation
3) artificial ventilation
4) Insertion of an OPA/NPA
5) endotracheal intubation
6) transcutaneous pacing
7) advanced resusitation drugs such as, but not limited to, vasopressors, antiarrhythmic agents and opioid antagonists

Question 33

For the purposes of providing comfort (palliative) care, the paramedic (according to scope of practice) or firefighter (according to skill level) WILL provide interventions or therapies considered necessary to provide comfort or alleviate pain. These include, but are not limited to, what?

Answer 33

1) provision of oropharyngeal suctioning
2) oxygen
3) nitroglycerin
4) salbutamol
5) glucagon
6) epinephrine for anaphylaxis
7) morphine (or other opioid analgesic)
8) ASA
9) benzodiazepines

Question 34

What are the two acceptable reasons for DNR, as listed on the DNR confirmation form?

Answer 34

1) A current tx plan exists that reflects patient’s expressed wish when capable, or consent of the SDM when patient is incapable, that CPR not be included in the patient’s plan of treatment
2) The physician’s current opinion that CPR will almost certainly not benefit the patient and is not part of the plan of treatment, and the physician has discussed this with the capable patient, or SDM when patient is incapable

Question 35

True or False. If a DNR confirmation form has been fully completed, use of photocopies are permitted and just as valid.

Answer 35

True

Question 36

In the context of a DNR, what steps shall a paramedic take upon arrival to a scene?

Answer 36

1) initiate care as per BLS PCS until presented with DNR
2) check the validity of the DNR and if not valid, continue resuscitation
3) ensure DNR applies to the patient being treated
4) stop resuscitation if vaild DNR and notify applicable authority

Question 37

When would a paramedic not honour a validity form when on scene?

Answer 37

1) when there is no valid confirmation form
2) capable patient wishes to be resuscitated
3) SDM rescinds confirmation form
4) there is confusion re: who the SDM is and/or people at the scene are demanding CPR

Question 38

When on scene and patient has valid DNR but not in cardiac/respiratory arrest, what should a paramedic do?

Answer 38

1) Confirm presence of DNR
2) utilize palliative care techniques
3) allow non-medical escort (at the discretion of the paramedic crew)

Question 39

What is a paramedic’s directives if death occurs during transport to a patient with a valid DNR?

Answer 39

1) confirm death by performing respiratory & pulse check for 3 minutes
2) note time of death and notify dispatch of situation and presence of valid DNR
3) continue transport to receiving factility

Question 40

True or False: If a patient dies while en route to hospital, this changes their code?

Answer 40

False. If they initially presented as almost resus and die midway, your are still transporting them CTAS 1

Question 41

If death occurs during transport and you were bringing the patient back to a private residence, what would your next steps be?

Answer 41

Turn around and go back to medical facility

Question 42

True or False. If interventions were provided for the patient and then a DNR was presented to you, remove all life-saving interventions that fall under CPR (i.e. remove OPAs/NPAs, defib pads)

Answer 42

False. Any intervention done stays with patient if already started

Question 43

In all cases of death (expected or unexpected), what shall the paramedic do, according to the Deceased Patient Standard (7)?

Answer 43

1) confirm patient is deceased as per Definitions
2) ensure that the Deceased Patient is treated with respect and dignity
3) consider the needs of family members of the decedent and provide compassion-informed decision-making
4) in cases of suspected foul play, follow directions set out in the Police Notification Standard
5) If applicable, follow all directions issued by a coroner or coroner’s delegate of any powers or authority pursuant of the Coroners Act (Ontario)
6) If termination of resuscitation occurs in the ambulance en route to a health care facility, advise CACC/ACS to contact the coroner, and continue to destination unless otherwise directed by CACC/ACS
7) for cases of obvious death, note and document time at which the paramedic confirms the patient was deceased as per the Standard

Question 44

In cases of unexpected death, what shall a paramedic do, as per Deceased Patient Standard (4)?

Answer 44

1) in the absence of police/coroner on scene, advise CACC/ACS of the death and they will notify the police/coroner
2) if coroner indicates they will attend the scene, paramedic shall remain at the scene until they arrive and assume custody of the Deceased Patient OR if they indicate they won’t attend the scene, the paramedic shall remain on scene until the arrival of whoever the coroner appointed/delegated powers and authority pursuant of the Coroners Act
3) notwithstanding paragraph 2 above, if police are present and have secured the scene, the paramedic may depart as soon as documentation has been completed or he/she is assigned to another call
4) where at any time the paramedic has not received any further direction from CACC/ACS, the paramedic shall request that CACC/ACS seek direction from the coroner re: paramedic’s responsibilities, including whether they may leave the scene

Question 45

True or False. Although a death may be viewed as “unexpected” by whoever is reporting the death (paramedic, family members), this does not necessarily imply that the death requires investigation by a coroner under the Coroners Act (Ontario)

Answer 45

True

Question 46

In cases of expected death, what shall a paramedic do, as per Deceased Patient Standard (7)?

Answer 46

1) paramedic shall advise CACC/ACS of death
2) make a request of a Responsible Person (if one is present) to notify primary care practitioner or member of Pallative Care team (if any) of the patient and request their attendace at the scene
3) if Responsible person is unable to provide the notice as above, the paramedic shall advise CACC/ACS of death and CACC/ACS will attempt to notify the primary care practitioner/member of Pallative Care Team and request their attendance at the scene
4) If the Deceased Patient’s primary care practitioner or Palliatve Care Team member is contacted and indicates they will attend the scene, the paramedic will remain at scene until their arrival
5) notwithstanding (4), if there is a Responsible Person present, and the paramedics reasonably believe that the Responsible person will remain until the primary care practitioner/Palliative Care Team member arrives, then the paramedic may depart as soon as all required documentation has been completed or if assigned to another call (alteratively if police are at scene and willing to stay until any of the above mentioned arrive, paramedic may leave the scene)
6) if primary care practitioner/Palliative Care Team member cannot be contacted or if he/she is unable to attend, or there is no Responsible Person on scene, the paramedic crew shall advise CACC/ACS in which case CACC/ACS shall notify police or coroner of the death and there there is no one else at scene who can take responsible for the Deceased Patient
7) if requested by coroner, paramedic will provide them with the circumstances of the death; paramedic will either be released from scene or instructed to remain with Deceased Patient until coroner or person appointed/delegated by Coroner OR responsible person can attend the scene and assume responsibility for the Deceased Patient

Question 47

In cases of all deaths, what are the 6 main steps that a paramedic shall do?

Answer 47

1) complete an ACR always
2) treat the deceased with respect and dignity
3) if suspected foul play, contact police
4) follow direction by the coroner or their delegate
5) if the death or TOR occurs en route to the hospital, let CACC/ACS know so they can notify coroner, and then continue transporting to receiving facility
6) always be thorough with your documentaiton and ensure a copy is left at the scene with coroner