A Do Not Resuscitate (DNR) order is a legally binding medical directive instructing healthcare providers to withhold cardiopulmonary resuscitation (CPR) and other aggressive life-sustaining measures if a person’s heart stops or they stop breathing. Individuals with terminal illnesses often seek this order to experience a natural death, avoiding the potential trauma and low success rate of resuscitation efforts. Hospice care is a specialized form of comfort-focused care for patients with a prognosis of six months or less, emphasizing quality of life and symptom management. When emergency medical services (EMS) are called to a hospice patient, the DNR order guides the actions of Emergency Medical Technicians (EMTs) at the intersection of comfort care and emergency response.
Validating the DNR in the Pre-Hospital Setting
A standard DNR order placed in a hospital chart is not sufficient for EMTs responding to a patient’s home or a non-facility setting. EMTs must adhere to specific, state-recognized pre-hospital DNR forms to legally honor the patient’s refusal of resuscitation. These specialized documents, often called Out-of-Hospital DNR forms, Physician Orders for Life-Sustaining Treatment (POLST), or Medical Orders for Life-Sustaining Treatment (MOLST), are designed to be immediately actionable by emergency personnel.
These pre-hospital forms differ from a living will because they constitute a direct physician order, not just an expression of future wishes. For EMTs to accept the directive, the document must be physically present at the scene and clearly visible. The form must contain the signatures of the patient or their decision-maker, and the attending physician, affirming the decision was informed and voluntary. The presence of a DNR identification device, such as a state-approved wristband or necklace, is often considered conclusive evidence of a valid order, even if the paper form is not immediately available.
Hospice Care and the DNR Framework
Enrollment in a hospice program signifies that a patient has chosen comfort care and is no longer seeking aggressive, curative treatments. While this focus aligns with the philosophy of a DNR, hospice status alone does not automatically create a legally binding pre-hospital DNR that EMTs can honor. EMT protocol requires specific, verifiable documentation, not just a verbal confirmation of hospice enrollment.
Hospice providers are responsible for coordinating care and often proactively assist patients and families in completing the necessary pre-hospital DNR forms. This coordination ensures the patient’s wish to forego resuscitation will be respected if an emergency arises outside of a medical facility. A DNR order is narrow, applying only when the heart or breathing stops, and it does not affect the provision of comfort care for other issues, such as pain or bleeding.
EMT Protocol for Applying the DNR Order
When EMTs arrive at the scene of a hospice patient who has collapsed, their first action is to quickly assess the patient to confirm cardiac or respiratory arrest. If the patient is not in arrest, the DNR order has no bearing on their care, and the EMTs will provide full treatment for conditions like pain, shortness of breath, or hemorrhage. However, once arrest is confirmed, the EMTs must immediately locate and verify the specific pre-hospital DNR form or identification device.
Verification involves checking that the document is the appropriate state-specific form and that it has been properly completed, including signatures and dates. Upon confirming the validity of the DNR, EMTs must withhold all resuscitative interventions, including chest compressions, assisted ventilation, defibrillation, and certain cardiac medications. The focus of care then shifts entirely to comfort measures, such as repositioning the patient, ensuring a clear airway, and providing pain or anxiety medication.
The EMTs contact medical command or the base hospital physician to report the situation, verify the death, and receive direction on documentation and pronouncement. This step ensures the decision to withhold resuscitation is formally documented and sanctioned by the medical control system. The protocol upholds the patient’s wishes for a peaceful death.
Actions When Documentation Is Unclear or Absent
The absence of a valid, verifiable pre-hospital DNR form creates an imperative for EMTs to initiate full resuscitation efforts. Even if family members verbally confirm the patient is in hospice and has a DNR, EMTs must begin CPR and other aggressive measures if the paperwork is missing or appears invalid. EMTs cannot rely on verbal statements alone to withhold life-sustaining treatment.
If resuscitation is started and the family subsequently finds a valid, completed DNR form, the EMTs are legally obligated to stop all resuscitative efforts immediately. The protocol requires EMTs to provide full treatment until the documented, legal instruction to withhold care is physically presented and verified. This underscores why proper documentation is the most important factor in honoring a patient’s end-of-life wishes in a 911 emergency.