| 1. | WHAT
IS THE PURPOSE OF THIS POLICY? |
| This policy is designed to address those situations
in which patients have made a special request regarding withholding
certain medical interventions in the event of an impending or actual
cardiac arrest. A cardiac arrest is the medical term for when the heart
stops beating and breathing ceases. The term "resuscitate"
refers to CPR and other medical procedures performed in an attempt to
re-start the heart (e.g. defibrillation [electrical shock], medications
and artificial ventilation). |
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| 2. | WHY
IS THIS POLICY NECESSARY? |
| As of August 1, 1996, new legislation allows EMS
personnel to comply with a patient's wishes and honor a document which
would notify EMS personnel of the patient's wish to not initiate
resuscitation. The law specifies that a particular form be developed
with specific criteria and be utilized in each county. In order to
comply with this law and acknowledge a patient's desire in these
situations, Kent County EMS has developed a "Do Not Resuscitate
Order". |
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| 3. | IN
WHAT SITUATIONS WILL EMS PERSONNEL HONOR A REQUEST TO NOT INITIATE
RESUSCITATION? |
| Pre-hospital personnel in Kent County will honor a
request to not initiate resuscitation only if a valid "Do Not
Resuscitate" form is physically present with the patient or the
patient has a clearly identified "Do Not Resuscitate" bracelet
in place with the patient's name and address and physicians name
and address noted. If a form is presented that is not clearly a valid
"Do Not Resuscitate" order, EMS personnel will have to
initiate care while they are contacting the physician in the emergency
department to discuss the situation. |
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| 4. | WHY
ARE OTHER FORMS NOT ACCEPTABLE? |
| The Michigan Attorney General's office has
determined that Advanced Directives and Living Wills, etc. do not apply
in the out-of-hospital setting. At the time of a medical emergency, it
is not reasonable to expect pre-hospital personnel to adequately
evaluate the many types of documents/forms/written orders (which many
times are not legible) for validity. The development of this specific
document ("Do Not Resuscitate" Order) is an attempt to comply
with the new Michigan Public Act No. 192 and 193 of 1996 in a manner
which will be quickly recognized and accepted by pre-hospital personnel.
The law specifies that the form must be "substantially
similar" to the form specified in the law; the Kent County EMS form
does that. |
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| 5. | HOW
DO WE COMPLETE THE FORM? |
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The "Do Not Resuscitate" Order must be
completed in its entirety for it to be considered valid. For this form to be valid: 1. The declarant (patient) must be over 18 years of
age and of sound mind; 2. The order MUST be dated and signed by each of
the following: a. The declarant (patient) or another person who,
at the time of the signing, is in the presence of the declarant and
acting pursuant to the direction of the declarant. b. The declarant's attending physician. c. Two witnesses 18 year of age or older, at least
one of which is not the declarant's spouse, parent, child, grandchild,
sibling or presumptive heir. The names of those signing the form must be
printed or typed below the corresponding signature. At any time after the form is completed and
witnessed, the declarant or an individual designated by the declarant
may apply an identification bracelet to the declarant's wrist. The
bracelet must be imprinted with the words "DO NOT RESUSCITATE
ORDER", in a type size that is as easily read as practical, and
include the name and address of the patient and the name and address of
the patient's physician, if any. A declarant who executes this "Do Not
Resuscitate" order shall maintain possession of the order and must
have the order accessible within his or her place of residence. The
written form or the bracelet must be physically present with the
patient. An attending physician who signs a declarant's "Do Not Resuscitate" order shall immediately make a copy or obtain from the declarant a duplicate of the executed order and make that copy or duplicate part of the declarant's permanent medical record. |
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| 6. | WHY
IS THE COBRA NOTICE AND WAIVER REQUIRED? |
| Federal law requires that any patient that presents
to an emergency department (regardless of the manner in which the
patient arrives...by private car or ambulance) be given a screening
examination by emergency department personnel sufficient to determine
the nature of the medical problem and to ensure that an emergency
medical condition does not exist. When an emergency medical condition
does exist, the patient must be stabilized to the greatest extent
possible. Obviously, this federal requirement may be in direct conflict
with the patient's wishes as expressed by this "Do Not
Resuscitate" order. By signing this waiver form, if the patient is
transported to the hospital, the emergency department will not be bound
by the federal law which would otherwise apply. This waiver form must be
completed and made available to EMS personnel on their arrival to care
for the patient and must be taken to the emergency department if the
patient is transported. |
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| 7. | WHAT
SHOULD THE PATIENT OR PATIENT'S ADVOCATE DO WITH THE FORM? |
| Once the "Do Not Resuscitate" form has
been completely filled out, the form should be kept in a location
(preferable with or near the patient) where it will be immediately
accessible in the event of a medical emergency. The forms should be
immediately presented to EMS personnel as soon as they arrive on the
scene. If the patient elects to also use a bracelet, that must be with
the patient. |
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| 8. | WHY
MUST THE "DO NOT RESUSCITATE" FORM BE SIGNED BY THE PATIENT'S
PHYSICIAN? |
| Decisions regarding care to be provided in the
event of a medical emergency can often be difficult decisions to make.
The requirement that the patient's physician sign the form will help
insure that the patient and physician have talked about this decision.
This way, hopefully, the patient is making an educated, well-informed
decision and will have had the opportunity to have any questions
answered by the physician. The law requires that the physician sign the
form, except in those situations when the "Do Not Resuscitate"
decision is based on a religious belief against medical care. |
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| 9. | WHAT
SHOULD BE DONE IF THE "DO NOT RESUSCITATE" DECISION IS BASED
ON RELIGIOUS BELIEFS? |
| A person who is "an adherent of a church or
religious denomination whose members depend on spiritual means through
prayer alone for healing" may execute a "Do Not
Resuscitate" order without requiring a physician's signature. A
different form is required for that purpose. A copy of that form may be
obtained from Kent County EMS. |
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| 10. | WHAT
SHOULD THE PATIENT DO IF HE/SHE CHANGES THE DECISION ABOUT
RESUSCITATION? |
| Any competent patient is able to make a change in
decisions such as this at any time. If a patient who has previously
completed a form wishes to change the level of care to be provided in a
medical emergency, he/she may do so at any time. If the change is to
request a full resuscitation/care, the previously completed form (and
any bracelet) can just be discarded. The patient's physician should be
informed of that decision. |
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| 11. | WHAT
IS THE "AMBULANCE TRANSPORTATION GUIDELINES" PAGE FOR? |
| This page has been developed to provide persons and
facilities (e.g. nursing homes, foster care homes, etc.) with suggested
guidelines on what to do regarding EMS activation or requests for
transport in particular situations which might arise affecting patients
with "Do Not Resuscitate" orders in place. For example, when a
patient who has requested to not be resuscitated by completion of this
document suffers a cardiac arrest, it is best to notify the patient's
personal physician rather than calling 911. There is also room on the
form to list important medical telephone numbers to assist locating
those numbers quickly. |
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| 12. | WHAT
SHOULD A FAMILY MEMBER OR HEALTH CARE WORKER DO IF A PATIENT WHO HAS
COMPLETED ONE OF THESE FORMS EXPERIENCES AN ACUTE MEDICAL PROBLEM OR
EMERGENCY? |
| If a person who has signed one of these forms
develops an acute medical problem or emergency for which they would like
treatment, call 911 to initiate a response from EMS. EMS personnel will
provide whatever supportive medical care the patient requires within the
guidelines the patient has indicated. |
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| 13. | WHAT
SHOULD A FAMILY MEMBER OR HEALTH CARE WORKER DO IF A PATIENT WHO HAS
COMPLETED ONE OF THESE FORMS EXPERIENCES A CARDIAC ARREST? |
| If a person who has signed this form and indicated
a desire not to undergo a full resuscitation experiences a cardiac
arrest, 911 should not be called. In that situation, the
patient's personal physician should be contacted. |
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| 14. | WHAT
CAN PHYSICIAN OFFICES DO TO FACILITATE USE OF THIS POLICY? |
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Physicians in Kent County are encouraged to work
with their patients who have expressed a desire to not receive
resuscitation in the event of a cardiac arrest to see that all of those
patients have completed this form. Personal physicians are very
important to the appropriate education of patients in working through
this decision-making process. Multi-physician groups are encouraged
to communicate to all physicians in the group the names of those
patients who have completed this form. That communication is
especially important when physicians are taking after-hours call for
associates. |
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| 15. | HOW
WILL THIS POLICY AFFECT THE LEVEL OF CARE PROVIDED TO PATIENT IN OTHER
SITUATIONS? |
| This policy will in no way affect the level
or type of care which patients will receive in any situation other than
a respiratory or cardiac arrest. Patients will continue to receive all
other types of appropriate supportive care as would normally be
expected. |
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| 16. | IS
THIS FORM ONLY EFFECTIVE IN MICHIGAN? |
| Because this form complies with the new state law,
it will be honored by EMS personnel any place in Michigan. It does not
apply outside the state. |
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| 17. | WHAT
SHOULD I DO IF I ALREADY COMPLETED A "SPECIAL PATIENT CONSIDERATION
FORM" (THE OLD KENT COUNTY FORM)? |
| EMS personnel in Kent County will continue to honor
the old form for several months, until you can complete the attached
"Do Not Resuscitate" form. You are encouraged to complete the
new form, and have it signed by your doctor, as soon as possible. You do
not have to return the new form to Kent County EMS as you did for the
"Special Patient Considerations" form previously. Once the new
form has been completed, please discard the old "Special Patient
Considerations" form. |
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| 18. | WHO
SHOULD WE CALL IF THERE ARE QUESTIONS ABOUT THIS FORM? |
| Any questions about this policy, its
implementation, or the form should be directed to Kent County EMS at
(616) 451-8438. |
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