Information Bulletin
Do Not Resuscitate Confirmation Form (DNRC)
January 2008
Academic Standards & Evaluation
Office of the Fire Marshal
Do Not Resuscitate (DNR) Confirmation Form
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.
Frequently Asked Questions
Do Not Resuscitate (DNR) Standard
- 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.
- 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.
- Will the DNR Confirmation Form be available in English and French?
Yes. It will have English on one side and French on the other.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
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
- Identify what criteria a Do Not Resuscitate Confirmation Form must contain
in order to determine its validity.
- Describe what actions for victim care you would initiate.
- Explain what additional steps should be taken on this call.
- Upon your return to the station, identify what protocols should be completed.
ANSWERS
- 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.
- 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.
- 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.
- 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
- Describe what actions for care you would initiate.
- In the event that a DNR Confirmation Form is not present, explain what protocols
you must follow.
- Identify what subsequent steps should be followed on this call.
- Upon your return to the station, identify what protocols should be completed.
ANSWERS
- 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.
- 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.
- 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.
- 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
- Identify what criteria the Do Not Resuscitate Confirmation Form must contain
in order to determine its validity.
- Describe what steps you would take for care.
- Explain how you would respond to the husband’s request with regards to the
Do Not Resuscitate Confirmation Form.
- Identify what additional steps you would take on this call.
- Upon return to the station, what procedures need to be taken to complete
this call.
ANSWERS
- 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.
- 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.
- 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.
- 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.
- 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
- Identify what actions for care you would initiate.
- Explain the protocol for an out-of–province Do Not Resuscitate form.
- Explain what additional steps should be taken on this call.
- Upon your return to the station, identify what protocols should be completed.
ANSWERS
- 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.
- 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.
- 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 .
- 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
- Describe what actions for care you would initiate.
- Explain what protocols must be followed in this scenario.
- What additional steps should be taken on this call?
- Upon your return to the station, identify what protocols should be completed.
AANSWERS
- 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.
- 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.
- 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.
- 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
- Identify what criteria a Do Not Resuscitate Confirmation Form must contain
in order to determine its validity.
- Discuss how you would deal with the requests made by the family members
regarding the DNRC Form.
- Describe what actions for care you would initiate.
- List what additional steps need to be taken on this call.
- Upon your return to the station, identify what protocols should be completed?
ANSWERS
- 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.
- 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.
- Describe what actions for care you would initiate.
- Start life sustaining measures, i.e. CPR.
- 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.
- 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.
Operational Guideline Template
SAMPLE
Date: Operating Guideline
No:
Do Not Resuscitate Confirmation Form (DNRC)
Purpose:
To provide guidance and information on dealing with
“Do Not Resuscitate Confirmation (DNRC) forms.
Scope:
This operating guideline is for all personnel responding
to VSA patients during a medical assist response.
Policy
Firefighters will honour the DNR order when presented
with a valid DNR Confirmation form. It provides a standardized process for firefighters
to follow that is consistent across the province and will minimize any chance
of error and reduce the risk of liability to firefighters.
Responsibility:
It is the responsibility of all Department personnel
to be fully aware of this operating guideline. Fire officers must ensure that
personnel under their direction continue to make all reasonable effort, to provide
the expected levels of emergency medical care, without compromising the dignity
of all persons concerned.
Procedures:
- When a firefighter becomes aware of the existence of a DNRC
Form, they will obtain the Form from the patient, family member
or caregiver at the scene.
- The firefighter will review it to ensure it is valid by the presence
of the unique serial number and by the completion of all required fields,
ie: patient’s name, a tick box has been checked to identify that one of
the conditions has been met; a signature by physician or nurse; the date
the form was signed.
- Perform a patient assessment and confirm the physical condition of patient.
• Obtain information regarding patient’s medical history; D.O.B; age; address.
- Assist responding EMS personnel and police as required.
- Upon return to station, the officer in charge will fully document the
event in the remarks section of the incident report and document the unique
serial number. Crew personnel attending the incident should prepare a written
summary of their actions and observations.
