Information Bulletin

Do Not Resuscitate Confirmation Form (DNRC)

January 2008

Academic Standards & Evaluation
Office of the Fire Marshal

Table of Contents

Introduction

Do Not Resuscitate (DNR) Confirmation Form

Appendix 1 – Frequently Asked Questions

Appendix 2 – Case Studies

Appendix 3 – Operational Guideline Template

Do Not Resuscitate (DNR) Confirmation Form

Introduction

Paramedics/firefighters often respond to calls where a patient on their own or through a substitute decision-maker has decided in advance that they do not wish to be resuscitated in the event that they suffer a respiratory or cardiorespiratory arrest. These situations require paramedics/firefighters to make rapid decisions whether or not it is appropriate to honour a Do Not Resuscitate request presented to them.

The Ministry of Health and Long-Term Care is introducing a DNR Form. This Form will be implemented on February 1, 2008.

The updated DNR Form will significantly enhance a first responder’s ability to honour the wishes of patients and their families when resuscitation is not part of the treatment plan for the patient. The Form has been designed for easier use by paramedics/firefighters while meeting the needs of patients and their families in all settings. It provides a standardized Form for all paramedics/firefighters to follow. This Form will minimize any chance of error and reduce the risk of liability to paramedics/firefighters.

This Information Bulletin has been developed to provide an opportunity to review the key points from the updated Do Not Resuscitate Confirmation Form (DNRC). This Form directs the practice of paramedics and firefighters after February 1, 2008 in situations where a DNR order is part of a patient’s treatment plan. Fire Departments will need to develop Standard Operating Procedures (SOPs) that incorporate the use of the DNR Confirmation Form for firefighters. These SOPs will be similar to the DNR Standard for paramedics. This Information Bulletin includes detailed information on the DNR Confirmation Form and its use.

Do Not Resuscitate Confirmation Form

The DNR Confirmation Form, when completed and signed by a medical doctor (M.D.), Registered Nurse (R.N.), Registered Nurse in the Extended Class [R.N. (EC)] or Registered Practical Nurse (R.P.N.) will confirm that the existing plan of treatment documented in the patient’s health care record does not include CPR.

The DNR Confirmation Form, when completed, provides direction to both paramedics and firefighters with respect to what patient care interventions may or may not be initiated for the patient during the time that they are responsible for patient care. Paramedics and firefighters are not required to review or confirm the actual DNR order on the patient’s health care record as the signatory of the Form is responsible to ensure that the order exists and that it is current.

The DNR Confirmation Form has a number of unique features that make it simpler to use for patients and their families, health care providers and paramedics. The Form is a single page, single copy, bilingual document. An English version of the Form is on one side of the page while a French version is located on the other side. This convenient feature negates the need to maintain separate inventories of the Form in both languages.

Each DNR Confirmation Form will be imprinted with a unique seven-digit serial number in the upper right hand corner. There are several advantages to having a serial number on the Form. Having a unique serial number assists paramedics/firefighters in determining the authenticity of the Form as only designated health care providers and institutions will have access to ordering the Form. Paramedics/firefighters who are presented with a Form without the serial number should question the authenticity of the Form and not accept it as a valid Form. Having a unique serial number on the Form will also assist in patient tracking should the need arise.

The DNR Confirmation Form is considered a durable document. This means the Form can be used as many times as necessary. This adds convenience as a health care provider is not required to complete and sign a new Form each time a patient is transported in an ambulance. In addition, once the Form has been completed and signed by the patient’s health care provider, additional photocopies can be made, allowing for the safe keeping of the original document. Furthermore, the DNR Confirmation Form has no specified expiry date. By implication, the expiry date of the Form coincides with the date of the patient’s death unless the patient’s treatment plan changes to include cardiopulmonary resuscitation or the patient, or substitute decision-maker on behalf of the patient, expresses a wish that CPR be initiated in the event of a respiratory or cardiorespiratory arrest. The rescinding of the DNR order may be made by the patient or substitute decision-maker at any time and may not necessarily be documented in the patient’s health care record.

Determining the Validity of a Do Not Resuscitate Confirmation Form

Paramedics/firefighters must confirm that all of the mandatory applicable fields on a DNR Confirmation Form are completed and that the Form is signed by a designated health care provider. Incomplete Forms cannot be considered valid and if an incomplete Form is received, paramedics/firefighters will not be permitted to honour the Do Not Resuscitate request.

Each section of the DNR Confirmation Form will be described in detail below. This exercise will assist paramedics/firefighters in determining the validity of a Form being presented to them and provide additional clarity on the information required in specific areas on the Form.

Each DNR Confirmation Form will be imprinted with a seven-digit unique serial number in the upper right hand corner. Forms without this serial number cannot be considered valid.

This section of the DNR Confirmation Form contains a statement describing the purpose of the Form. It is this statement that provides direction to paramedics and firefighters, enabling them to honour a DNR order made on behalf of the patient identified in the “Patient’s name” field found directly below the statement.

The statement in this section also sets forth the patient care interventions that will or will not be initiated by paramedics or firefighters when the Form is completed and signed by a designated health care provider.

Point 1 of this section, located directly below the patient’s name, includes the definition of “Do Not Resuscitate”. In addition, it provides a list of specific examples of interventions that are considered a part of cardiopulmonary resuscitation and as such, are not to be initiated by paramedics/firefighters for a patient with a valid DNR Confirmation Form.

The health care provider who completes and signs the DNR Confirmation Form is confirming that one of the two conditions indicated in this section has been met and is documented in the health care record of the patient named on the Form. This requires that the signatory exercise due diligence by confirming that the information is correct before signing the Form. Paramedics/firefighters are not expected to investigate the condition under which a DNR order is made nor are they required to actually review or confirm the DNR order written in the patient’s health care record.

A check in the first tick box indicates that a plan of treatment exists in the patient’s health record and that this plan does not include CPR. Secondly, it indicates that the plan of treatment reflects the patients expressed wish when capable or the consent of a substitute decision-maker when the patient has been deemed incapable.

The second tick box is checked when it is a physician’s opinion that CPR will almost certainly not benefit the patient and that the decision not to include CPR in the patient’s treatment plan was discussed with the patient or the substitute decision-maker. A nurse can check this box and sign the Form if they know that this was the condition under which the patient’s plan of treatment (that does not include CPR) was developed. It is the responsibility of the health care provider signing the Form to ensure that the documentation in the health care record supports the information indicated in the DNR Confirmation Form.

This section of the DNR Confirmation Form requires that the signatory indicate their professional designation by checking the appropriate tick box, printing their surname and given name(s) in the areas indicated, signing and dating the Form.

On-Scene Directives

When a paramedic/firefighter becomes aware of the existence of a DNR Confirmation Form, they will obtain the Form from the patient, family member or caregiver at the scene. It should be noted that the validity of the DNR Confirmation Form is not dependent on the presence of the health care provider who completed and signed the Form being on the scene. Once the Form is obtained, the paramedic/firefighter should review it carefully to ensure that it is valid as indicated by the presence of the serial number and by the completion of all of the required fields that were identified in the previous sections. If it is determined that the DNR Confirmation Form is not valid for any reason, paramedics/firefighters must continue to provide care to the patient.

In addition to obtaining the completed DNR Confirmation Form and determining the validity of the Form, paramedics/firefighters must make all reasonable efforts to ensure that the patient named on the Form is the person to whom they are attending to. While it is preferable to have confirming documentation to identify the patient, it may not be feasible or practical to obtain this in all instances. Paramedics/firefighters may have to rely on verbal confirmation by the person at the scene who presented the DNR Confirmation Form to assist confirming the identity of the patient.

Summary

The updated Do Not Resuscitate Confirmation Form (DNRC) has been developed to better meet the needs of patients and their families in all settings when Do Not Resuscitate is part of their current treatment plan. The process has been designed to be easier to use by both first responders and health care providers responsible for the care of patients. The updated form promotes a standardized process for paramedics/firefighters to follow that ensures consistency across the province.

A list of “Frequently Asked Questions” that provide additional information regarding the DNRC Form and several case studies have been included with this Information Bulletin. Firefighters are encouraged to complete the case studies and evaluate their knowledge of the updated Do Not Resuscitate Confirmation form using the answer keys that have been provided. Firefighters are encouraged to review this Information Bulletin as required to maintain their familiarity and working knowledge of the form.

Any questions regarding the Do Not Resuscitate Confirmation Form should be directed to your training division for clarification.

Appendix 1

Frequently Asked Questions

Do Not Resuscitate (DNR) Standard

1. What does DNR mean?
   DNR stands for Do Not Resuscitate, which means that no resuscitative interventions (CPR) will be employed in the event that a person experiences respiratory or cardiorespiratory arrest. These interventions have been listed on the DNR Confirmation Form.
   
2. I have heard other acronyms and terms such as “No CPR”, “DNAR” (Do Not Attempt Resuscitation) and/or “AND” (Allow Natural Death). Do they mean the same thing?
   The terms in principle mean the same thing. Some people use these terms in an attempt to more precisely describe the health care interventions employed. Most of the time CPR is unsuccessful at restoring a person back to a point at which the person can sustain his/her own heartbeat and breathing. This is especially true for patients with advanced progressive life-limiting illness. So, to say “No CPR” or “DNAR” is more precise terminology. The main reason that DNR was chosen instead of these other terms is because the Taskforce believed that it would be the most recognizable and understandable term for first responders, families and other caregivers.
   
3. Will the DNR Confirmation Form be available in English and French?
   Yes. It will have English on one side and French on the other.
   
4. Will use of the Form be implemented across the province on one specific date or will it be implemented in stages?
   Implementation will occur on one specific date, February 1, 2008. All stakeholders are to be prepared for this effective date to ensure that the correct documentation is provided to paramedics/firefighters.
   
5.  How will this new information be shared with all stakeholders?
   There are a number of stakeholder groups being utilized around the province to ensure that this information will be distributed to those who need it.
   
6.  Will the DNR Confirmation Form be available for use on-line (electronically)?
   No, since there is a unique serial number that is imprinted on each Form, it is not currently possible to make the Forms available in any format other than hard copies.
   
7.  Who will be allowed to acquire DNR Confirmation Forms?
   Access to Forms will be restricted to health care facility staff and regulated health care providers authorized to sign the Form.
   
8.  How will a patient’s identity be confirmed as there are no fields for an Ontario Health Care Card number or birth date on the Form?
   The person’s full name will be sufficient to clearly identify the person to whom the Form applies. Paramedics and firefighters will also conduct usual due diligence in ensuring that the patient is the patient to whom the DNR Confirmation Form belongs.
   
9.  Will paramedics and firefighters use the same Standard/procedure?
   Essentially yes. Paramedics are governed by the MOHLTC, pursuant to the provisions of the Ambulance Act. Firefighters are managed by the municipalities of Ontario and their fire departments, each of which will have their own policies and procedures to direct their practice. Paramedics and firefighters will use the same Form and the same or similar processes. Paramedics will follow the DNR Standard within the current version of the Basic Life Support Standards, while each fire department will need to establish a standard operating procedure incorporating the DNR Confirmation Form to their current practices for distribution to firefighters.
   
10.  In the event of an expected death where the patient’s plan of treatment does not include CPR (and they have a signed DNR Confirmation Form) should the family call 9-1-1, will paramedics and firefighters still be sent to this emergency call?
    Yes. All emergency calls for service will be will be assessed and dispatched accordingly, regardless of any documentation that may be on the scene. It is the responsibility of the responding paramedics and firefighters to assess the situation upon their arrival, determine the validity of the DNR Confirmation Form and take the necessary next steps. Ambulance Communications Officers are trained to provide over-the-phone CPR instructions, however these can be declined by the caller, if desired.
    
11.  How will the DNR Confirmation Form be presented to the paramedics/firefighters?
    This will depend on the setting of patient care. If the patient is in a health care institution (e.g. hospital or long-term care facility), it is probable that a health care provider will present it to the paramedic/firefighter. However, if the patient is living at home, it is likely that he/she (or the SDM on behalf of an incapable patient or another family member or caretaker e.g. personal assistant) will present it to the paramedic/firefighter directly.
    
12.  What will need to be done in cases where there is a delay in the family or facility staff presenting the paramedic/firefighter with the fully completed DNR Confirmation Form and the patient experiences respiratory or cardiorespiratory arrest?
    For the paramedic/firefighter to not perform CPR on a patient who is in respiratory or cardiorespiratory arrest, he/she MUST receive a fully completed DNR Confirmation Form. This Form is the only directive that gives permission to paramedics and firefighters to not perform CPR on patients who have a DNR order and have experienced respiratory or cardiorespiratory arrest. If there is a delay in obtaining the fully completed DNR Confirmation Form and the patient experiences respiratory or cardiorespiratory arrest, the paramedic/firefighter will initiate CPR and continue it until such time as the DNR Confirmation Form is produced and the paramedic/firefighter determines it to be valid. CPR will then be discontinued.
    
13.  Will the attending paramedics/firefighters ever need to review the current treatment plan to confirm that a DNR Order actually exists?
    No. Before the DNR Confirmation Form is provided to the paramedic or firefighter, the physician or nurse will be responsible for ensuring that the plan of treatment is current and does not include CPR.
    
14.  Will there be a possibility of a paramedic/firefighter performing partial resuscitation measures (e.g. defibrillation but not chest compressions)?
    No. The DNR Confirmation Form and corresponding procedures were developed with the intent to expand currently existing policies so that the DNR needs of as many people as possible could be met. Many “partial resuscitation measures” would exceed the scope of most paramedics and firefighters. These types of requests can frequently result in demands that are difficult to interpret and impossible to meet. In this situation it is best to implement full resuscitation until a physician at the receiving emergency department can talk to the substitute decision-maker.
    
15.  Why is there no expiry date or a “sunset” clause for the DNR Confirmation Form?
    Ontario’s Health Care Consent Act is quite clear that the last known wishes of a patient are all that is required to direct treatment. Therefore, there is no need to set an expiry date. By implication, the DNR Confirmation Form expiry date is equivalent to the date of the patient’s death or the date at which the plan of treatment changes to include CPR. In the case of the latter event, the DNR Confirmation Form would not be provided to the paramedic/firefighter.
    
16.  Why is the patient or Substitute Decision-Maker (SDM) not required to sign the DNR Confirmation Form?
    Patient or SDM consent for the patient’s plan of treatment will have been obtained and documented in the patient’s health care record. The DNR Confirmation Form is simply documentation by a physician or nurse of what is already known so that the plan with respect to CPR can be continued by paramedics and firefighters.
    
17.  If a living patient has been receiving one or more treatments (e.g. intubation) that are listed on the DNR Confirmation Form as being treatments paramedics/firefighters are not to initiate, will paramedics/firefighters be required to stop these treatments upon assuming the patient into their care?
    No. The DNR Standard stipulates that “… a paramedic or firefighter will not initiate basic or advanced cardiopulmonary resuscitation (CPR)…”. There are many instances where patients are being maintained by intensive treatments (e.g. a person with a quadriplegia already requiring a home ventilator for life maintenance) for non-resuscitative purposes. To require paramedics/firefighters to withdraw these treatments in order to honour a DNR Confirmation Form would be inappropriate. Paramedics/firefighters will be permitted to maintain treatments that have already been initiated. However, if this patient has a valid DNR Confirmation Form and he/she goes into respiratory or cardiorespiratory arrest, no additional interventions of those listed in Section 1 of the DNR Confirmation Form will be started.
    
18.  How will paramedics/firefighters manage a call where the patient has a valid DNR Confirmation Form, but upon arrival the patient is dead?
    Do not begin resuscitative measures.
    
19.  Under what circumstances will it be possible to revoke the DNR Confirmation Form?
    The DNR Confirmation Form can be revoked when:
    
    •  the patient withdraws consent and expresses a wish to have CPR. Even if the request is vague or uncertain, paramedics and firefighters will err on the side of life and initiate CPR if there is any question about the validity of the DNR Confirmation Form;
    •  the SDM revokes the DNR Confirmation Form and requests CPR;
    •  a physician or nurse has determined that the plan of treatment has changed and now includes CPR. If the paramedic/firefighter cannot determine whether or not the DNR Confirmation Form is valid, they will err on the side of life and initiate CPR.

Appendix 2

Case Studies

Do Not Resuscitate Confirmation – Fire Services Training Information

SCENARIO # 1

Your fire department participates in tiered medical response for your community by authority of a by-law and Tiered Response Agreement with the local EMS provider. You are notified to respond to a residence for a male victim having severe breathing difficulty, turning blue and having a history of heart ailment.

During your response, you are advised that EMS will be delayed on arrival at your scene and the victim is now being reported as VSA (vital signs absent).

On arrival at the victim’s residence, a female who identifies herself as the victim’s wife meets you. She is calm and tells you that her husband is not breathing and that he has a Do Not Resuscitate Confirmation form, which she provides to you. She goes on to tell you that her husband has been ill for some time and his wish was to die at home.

QUESTIONS

1. Identify what criteria a Do Not Resuscitate Confirmation Form must contain in order to determine its validity.
   
    
    
   
2. Describe what actions for victim care you would initiate. 
   
    
    
   
3. Explain what additional steps should be taken on this call. 
   
    
    
   
4. Upon your return to the station, identify what protocols should be completed. 
   
    
    
   

ANSWERS

1. Identify what criteria a Do Not Resuscitate Confirmation Form must contain in order to determine its validity.
   
   By examining the Do Not Resuscitate Confirmation form to determine its validity, it should have:
   • Identification on the form indicating it is for “Ontario”;
   • The patient’s name – both surname and given name (first name);
   • A tick box that has been checked to identify that one of the conditions has been met;
   • A signature by the appropriate physician or nurse;
   • The printed name of the physician or nurse signing the form;
   • The date that the form was signed, which must be the same as or precede the date of request for assistance;
   • A tick box that has been checked to identify the professional designation of the physician or nurse who has signed the form;
   • A “unique” serial number that is visible on the form.
     
     
2. Describe what actions for care you would initiate.
   
   • Confirm the physical condition of the victim i.e. physical location, vital life signs, indications of trauma.
   • Provide assistance and comfort to the family members present.
   • You are able to comply with the family member request.
     
     
3. Explain what additional steps should be taken on this call.
   • Obtain information regarding the victim i.e. age, D.O.B., address, medical history. If the information request is not appropriate at the time, record the unique serial number for call documentation.
   • Notify fire service dispatch of victim situation and have responding EMS and police service notified of the situation at the residence.
   • Assist responding police service and EMS personnel, as required.
     
     
4. Upon your return to the station, identify what protocols should be completed.
   • Return to station, complete call documentation and provide de-briefing of the call for responding personnel.
   • Determine the requirement of Critical Incident Stress de-briefing for affected personnel.
      

SCENARIO # 2

Your fire department participates in tiered medical response for your community by authority of a by-law and Tiered Response Agreement with the local EMS provider. You are notified to respond to a residence for a male victim having a severe breathing difficulty, turning blue and having a history of heart ailment.

During your response, you are advised that EMS will be delayed on arrival at your scene and the victim is now being reported as vital signs absent (VSA).

On arrival at the victim’s residence, a female who identifies herself as the victim’s wife meets you. She tells you that her husband is not breathing, that her husband has been ill for some time and that his wish was to die at home. She also adds that they have a “living will” and not to do anything to her husband.

QUESTIONS

1. Describe what actions for care you would initiate. 
   
    
    
   
2. In the event that a DNR Confirmation Form is not present, explain what protocols you must follow.  
   
    
    
   
3. Identify what subsequent steps should be followed on this call.  
   
    
    
   
4. Upon your return to the station, identify what protocols should be completed. 
   
    
    
   

ANSWERS

1. Describe what actions for care you would initiate.
   
   • Confirm the physical condition of the victim i.e. physical location, vital life signs, indications of trauma.
     
     
2. In the event that a DNR Confirmation Form is not present, explain what protocols you must follow. 
   
   • Confirm the terminology for the form with the wife. You are not able to comply with the request of the wife, in that the “living will” is not acceptable for direction to not perform life-sustaining measures. Clarify and provide explanation with the wife that the form she has is not the Do Not Resuscitate Confirmation Form and that is the only form that first responders can accept for direction.
   • Start life sustaining measures i.e. CPR.
   • Provide assistance and comfort to the family members present.
     
     
3. Identify what subsequent steps should be followed on this call. 
   • Notify fire service dispatch of victim situation and have responding EMS and police service notified of the situation at the residence.
   • Obtain information regarding the victim i.e. age, D.O.B., address, medical history and medications for call documentation, if possible.
   • Assist responding police service and EMS personnel upon arrival at the scene, as required.
     
     
4. Upon your return to the station, identify what protocols should be completed.
   • Return to station, complete call documentation and provide de-briefing to personnel.
   • Determine the requirement of Critical Incident Stress de-briefing for affected personnel.
     

SCENARIO # 3

Your fire department participates in tiered medical response for your community by authority of a by-law and Tiered Response Agreement with the local EMS provider. You are notified to respond to a residence for a female victim having a severe breathing difficulty, turning blue and having a history of heart ailment.

During your response, you are advised that EMS will be delayed on arrival at your scene and the victim is now being reported as vital signs absent (VSA).

On arrival at the victim’s residence, a male who identifies himself as the victim’s husband, meets you. He is upset and tells you that his wife has stopped breathing “a moment ago” and that she has a Do Not Resuscitate Confirmation form, which he provides to you. He goes on to tell you that his wife has been ill for some time and her wish is to die at home. He informs you that he is the Substitute Decision Maker and he wants you to save her.

QUESTIONS

1. Identify what criteria the Do Not Resuscitate Confirmation Form must contain in order to determine its validity.
   
    
    
   
2. Describe what steps you would take for care. 
   
    
    
   
3. Explain how you would respond to the husband’s request with regards to the Do Not Resuscitate Confirmation Form.  
   
    
    
   
4. Identify what additional steps you would take on this call.
   
    
    
   
5. Upon return to the station, what procedures need to be taken to complete this call.
   
    
    
   

ANSWERS

1. Identify what criteria the Do Not Resuscitate Confirmation Form must contain in order to determine its validity.
   Examining and confirm the Do Not Resuscitate Confirmation form to determine that it is valid.  It should have:
   • Identification on the form indicating it is for “Ontario”;
   • The patient’s name – both surname and given name (first name);
   • A tick box that has been checked to identify that one of the conditions has been met;
   • A signature by the appropriate physician or nurse;
   • The printed name of the physician or nurse signing the form;
   • The date that the form was signed, which must be the same as or precede the date of request for assistance;
   • A tick box that has been checked to identify the professional designation of the physician or nurse who has signed the form;
   • A “unique” serial number that is visible on the form.
     
     
2. Describe what steps you would take for care.
   
   • Confirm the physical condition of the victim i.e. physical location, vital life signs, indications of trauma.
     
3. Explain how you would respond to the husband’s request with regards to the Do Not Resuscitate Confirmation Form. 
   • Talk to the husband and discuss the implications of going ahead with life sustaining measures for his wife i.e. her wish not to be revived; the expectations of her future health. If he insists on going forward with the resuscitation efforts, comply with his direction.
   • Start life sustaining measures i.e. CPR. 
     
     
4. Identify what additional steps you would take on this call.
   • Notify your fire service dispatch of the victim situation and have responding EMS and police service personnel notified of the situation at the residence.
   • Provide assistance and comfort to family members present, as required.
   • Obtain information regarding the victim i.e. age, D.O.B., address, medical history, medications, for call documentation and the unique identification number on the form, if possible.
   • Assist responding police service and EMS personnel upon arrival at the scene, as required.
     
     
5. Upon return to the station, what procedures need to be taken to complete this call? 
   • Return to station, complete call documentation and provide de-briefing to personnel.
   •  Determine the requirement of Critical Incident Stress de-briefing for affected personnel. 
     

SSCENARIO # 4

Your fire department participates in tiered medical response for your community by authority of a by-law and Tiered Response Agreement with the local EMS provider. You are notified to respond to a residence, identified as a bed & breakfast (B & B) for a male victim having severe breathing difficulty, turning blue and having a history of heart ailment.

During your response, you are advised that EMS will be delayed on arrival at your scene and the victim is now being reported as vital signs absent (VSA).

On arrival at the B & B, a female who identifies herself as the victim’s wife meets you. She tells you that her husband is not breathing, that her husband has been ill for some time and that his wish was to not be revived. She adds that they are from out-of-country and she has a Do Not Resuscitate Certificate from their home state of Pennsylvania, provides a copy to you and asks you not to do anything to her husband.

QUESTIONS

1. Identify what actions for care you would initiate.
   
    
    
   
2. Explain the protocol for an out-of–province Do Not Resuscitate form.  
   
    
    
   
3. Explain what additional steps should be taken on this call.
    
    
   
4. Upon your return to the station, identify what protocols should be completed. 
   
    
    
   

ANSWERS

1. Describe what actions for care you would initiate.
   
   • Confirm the physical condition of the victim, i.e. physical location, vital life signs, indications of trauma.
     
     
2. Explain the protocol for an out-of–province Do Not Resuscitate form. 
   
   • You are not able to comply with the request of the wife. Ensure clarity and provide explanation to the wife that the form she has is not the Ontario Do Not Resuscitate Confirmation Form. The Ontario Form is the only form that first responders can accept for direction.
   • Provide assistance and comfort to the family members and bystanders present.
     
     
3. Explain what additional steps should be taken on this call.
   • Start life sustaining measures, i.e. CPR.
   • Notify your fire service dispatch of the victim situation and have responding EMS and police service personnel notified of the situation at the scene.
   • Obtain information regarding the victim i.e. age, D.O.B., address, medical history and medications for call documentation, if possible.
   • Assist responding police service and EMS personnel upon arrival at the scene as required .
      
     
4. Upon your return to the station, identify what protocols should be completed.
   • Return to station, complete call documentation and provide de-briefing to personnel.
   • Determine the requirement of Critical Incident Stress de-briefing for affected personnel.
     
     

SCENARIO # 5

Your fire department participates in tiered medical response for your community by authority of a by-law and Tiered Response Agreement with the local EMS provider. Your department is notified to respond to the local mall where a male victim has collapsed in the parking lot and is possibly not breathing.

During your response, you are advised that EMS will be delayed on arrival at your scene and the victim is now being reported as VSA (vital signs absent).

On arrival you find a male victim lying on the ground beside the car. His wife states he is a very ill man and she has a Do Not Resuscitate Confirmation (DNRC) Form at home. She does not want CPR done to her husband.
 

QUESTIONS

1. Describe what actions for care you would initiate. 
   
    
    
   
2. Explain what protocols must be followed in this scenario. 
   
    
    
   
3. What additional steps should be taken on this call?
   
    
    
   
4. Upon your return to the station, identify what protocols should be completed. 
   
    
    
   

AANSWERS

1. Describe what actions for care you would initiate.
   
   • Confirm the physical condition of the victim i.e. physical location, vital life signs, indications of trauma.
     
2. Explain what protocols must be followed in this scenario.
   • You are not able to comply with the request of the wife. Provide explanation and ensure clarity to the wife that without presentation of the form, you are unable to comply with her request.
   •  Start life sustaining measures i.e. CPR.
   •  Notify your fire service dispatch of the victim situation and have responding EMS and police service personnel notified of the situation at the scene.
   •  Provide assistance and comfort to the family members.
      
     
3. What additional steps should be taken on this call?
   • Obtain information regarding the victim, i.e. age, D.O.B., address, medical history and medications for call documentation, if possible.
   •  Assist responding EMS personnel and police service upon arrival at the scene, as required. 
     
     
4. Upon your return to the station, identify what protocols should be completed?
   • Return to station, complete call documentation and provide de-briefing to personnel.
   • Determine the requirement of Critical Incident Stress de-briefing for affected personnel.
     
     

SCENARIO # 6

Your fire department participates in tiered medical response for your community by authority of a by-law and Tiered Response Agreement with the local EMS provider. You are notified to respond to a residence for a male victim with an unknown problem. The caller hung up.

During your response, you are advised that EMS will be delayed on arrival at your scene and the victim is now being reported as VSA (vital signs absent).

On arrival you find and elderly man and his son at the door. The older gentleman is agitated and leads you to his wife. She is on the couch and appears to be VSA. His son presents you with a Do Not Resuscitate Confirmation (DNRC) Form and states that her wishes were to die at home. The victim’s husband asks that you please save her and to do everything you can.

QUESTIONS

1. Identify what criteria a Do Not Resuscitate Confirmation Form must contain in order to determine its validity.
   
    
    
   
2. Discuss how you would deal with the requests made by the family members regarding the DNRC Form.  
   
    
    
   
3. Describe what actions for care you would initiate. 
   
    
    
   
4. List what additional steps need to be taken on this call. 
   
    
    
   
5. Upon your return to the station, identify what protocols should be completed? 
   
    
    
   

ANSWERS

1. Identify what criteria a Do Not Resuscitate Confirmation Form must contain in order to determine its validity.
   
   By examining the Do Not Resuscitate Confirmation form to determine its validity, it should have:
   • Identification on the form indicating it is for “Ontario”;
   • The patient’s name – both surname and given name (first name);
   • A tick box that has been checked to identify that one of the conditions has been met;
   • A signature by the appropriate physician or nurse;
   • The printed name of the physician or nurse signing the form;
   • The date that the form was signed, which must be the same as or precede the date of request for assistance;
   • A tick box that has been checked to identify the professional designation of the physician or nurse who has signed the form;
   • A “unique” serial number that is visible on the form.
     
     
2. Discuss how you would deal with the requests made by the family members regarding the DNRC Form.
   
   • Talk to the husband and discuss the implications of going ahead life with sustaining measures for his wife, i.e. her wish not be revived and the expectations of her future health. If he insists that his wife receives resuscitation, comply with his request.
   • Explain your actions to his son.
     
     
3. Describe what actions for care you would initiate.
   • Start life sustaining measures, i.e. CPR.
     
     
4. List what additional steps need to be taken on this call.
   • Obtain information regarding the victim i.e. age, D.O.B., address, medical history.
   • If the information request is not appropriate at the time, record the unique serial number for call documentation.
   • Notify fire service dispatch of victim situation and have responding EMS and police service notified of the situation at the residence.
   • Assist responding police service and EMS personnel, as required.
     
     
5. Upon your return to the station, identify what protocols should be completed.
   • Return to station, complete call documentation and provide de-briefing of the call for responding personnel.
   • Determine the requirement of Critical Incident Stress de-briefing for affected personnel.