SWORBHP Ask MAC

Answer: Thanks for the excellent question. This query has generated much discussion throughout our Base Hospital as well as with other Regional Base Hospitals across the Province.

The actual DNR standard itself speaks of “a person who has suffered respiratory or cardiorespiratory arrest” on many occasions. The standard directs paramedic practice “with respect to the management of situations where a patient…..has expressed the wish not to be resuscitated in the event that they experience a respiratory or cardiorespiratory arrest”.

Ironically, on the actual DNR confirmation form itself, nowhere does it state that a cardiac arrest must have occurred. Careful review of Part 1 of the form will show that the definition of “do not resuscitate” includes “advanced cardiopulmonary resuscitation (CPR)” which is defined as:

• chest compression
• defibrillation
• artificial ventilation
• insertion of a OPA or NPA
• endotracheal intubation
• transcutaneous pacing
• advanced resuscitation drugs such as vasopressors, antiarrhythmic agents and opioid antagonists.

You will note that CPAP is not listed as being contra-indicated on this form. Given that in order for the DNR to “kick in”, patients must have suffered (as above) a respiratory or cardiac arrest, and given that a patient must be spontaneously breathing in order to qualify for CPAP (and have a stable blood pressure), we believe by mutual exclusion, paramedics are bound to follow their medical directives for patients in respiratory distress and this would include CPAP.

The wording on the DNR Confirmation Form does however speak to artificial ventilation and the insertion of an oropharyngeal or nasopharyngeal airway as being contraindicated. CPAP represents high flow oxygen being passively applied with positive pressure (the patient is still required to do the ventilation and have be breathing spontaneously). In our view, CPAP alone does not constitute artificial ventilation. As such, when the appropriate conditions are met, a patient in respiratory distress from presumed COPD or pulmonary edema may have CPAP applied as per the medical directive even when that patient has a valid DNR Confirmation Form. In fact, we feel the provision of CPAP may alleviate distress and provide comfort to these patients and may even avoid the need for intubation for these critically unwell patients (which would be contraindicated by the DNR).

A link to the DNR Standard can be found on our website here:
http://www.lhsc.on.ca/About_Us/Base_Hospital_Program/No.108V.1.0DNRStandard.pdf

Thanks again for the outstanding question.