Answer: Thank you for your question. It is a confusing area of practice. The short, straight forward, policy answer is that paramedics provide resuscitation procedures to everyone who requires them UNLESS the patient has a signed Ministry of Health / Fire Marshall approved DNR form indicating there is a DNR plan in place or there is a signed inter-facility DNR order. If the form is not available to be checked then resuscitative measures should be started until the form is produced.
While we wish to follow a person’s wishes regarding their end of life, the dilemma is that resuscitation in cardiac arrest is a time sensitive situation. The default expectation is to begin resuscitation if someone calls 911 and requests assistance. A paramedic does not have the luxury of spending time to sort out what the person’s wishes are, who is the designated alternate decision maker is if the person is not capable of indicating their own wishes etc.
As you correctly point out, the real world is not so clear. People frequently don’t discuss their end of life wishes. When they do, they often don’t write down their wishes. They seldom do so on an “approved” form. Likely the person or their family doesn’t know such a form exists. The form requires substantial effort to obtain.
The problem is what to do; when the form does not exist, when it can’t be readily produced, or when a family member is clearly stating the person does not want resuscitation. It is tempting to follow the direction of the family member but this action does not comply with the standard.
We suggest the following compromise. If an approved form is not readily produced to examine and bystanders indicate the patient does not wish resuscitation then CPR or other resuscitative measures should begin. One of the paramedics should obtain the details and explain that they are obliged to begin until the situation is clarified. This information should be relayed in a patch to the Base Hospital physician and discussed. In most cases the paramedic will be given a cease resuscitation order and the resuscitation can be stopped.
While this is not an ideal solution, this course of action balances the legal obligations and moral claims to respect the autonomy and wishes of the patient. Everyone should be encouraged to discuss their end of life wishes with their family and to document their wishes appropriately.