Planning for end-of-life care involves making decisions that ensure personal wishes are honored, especially when facing a terminal illness. A significant challenge is bridging the gap between a patient’s medical orders and the rapid-response protocols of emergency services. When an emergency occurs at the home of a patient receiving hospice care, Emergency Medical Technicians (EMTs) must quickly determine the appropriate level of intervention. This procedure relies entirely on specific, legally-recognized documentation that translates a patient’s choices into immediate instructions for first responders.
Understanding DNR and Hospice Care Context
A Do Not Resuscitate (DNR) order is a precise medical instruction written by a physician, directing healthcare providers to withhold cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. This order specifically prohibits interventions like chest compressions, artificial ventilation, and defibrillation. For patients with advanced, terminal illnesses, the physical trauma of resuscitation often leads to poor outcomes, such as fractured ribs or neurological damage.
Hospice care represents a shift in treatment, moving the focus from curative measures to comfort and quality of life. For many hospice patients, the goal aligns with accepting the natural progression of their disease, making a DNR order a common component of their care plan. However, a standard DNR order on a hospital chart or a living will is not sufficient for first responders arriving at a home. EMT protocols require a highly specific, portable form that functions as an immediate, valid medical order in the pre-hospital setting.
The Critical Role of Portable DNR Documentation
Standardized, portable documentation must be in place to ensure a patient’s wishes are respected outside of a medical facility. The most widely recognized of these forms are the Physician Orders for Life-Sustaining Treatment (POLST) or similar state-specific forms like Medical Orders for Life-Sustaining Treatment (MOLST). These documents are distinct from advance directives because they are actionable medical orders, signed by both the patient (or surrogate) and a physician.
These forms translate the patient’s preferences into a set of standing medical orders that are immediately executable by any healthcare provider, including EMTs. They typically address not only the DNR status but also other levels of intervention, such as whether to use antibiotics, artificial nutrition, or mechanical ventilation. Many state protocols recommend or require the use of brightly colored paper, such as pink or green, to ensure the document is highly visible and easily found by first responders in an emergency.
The hospice provider holds responsibility for ensuring this document is correctly completed, signed, and placed in an accessible location, often on the refrigerator or near the patient’s bedside. Because laws governing these documents vary significantly by state, the documentation must be the exact form recognized by the local Emergency Medical Services (EMS) system. Without the valid, physical pre-hospital document, EMTs are required by law to initiate full resuscitation efforts, overriding the patient’s stated wishes.
EMT Protocol: Applying the DNR in the Home Setting
When EMTs are called to the home of a hospice patient, their response begins with a rapid assessment of the situation and the presence of proper documentation. Upon arrival, the first step is to identify any indicators that the patient is under hospice care or has a standing DNR order, which may include a special bracelet, necklace, or prominent signage. The EMT team must then locate and verify the validity of the state-approved portable medical order, such as the POLST form, checking for the required signatures.
If a valid pre-hospital DNR or POLST form instructing no resuscitation is found, the EMTs will immediately withhold all forbidden resuscitative measures. The DNR order is a boundary, limiting what the EMTs can do; it does not mean they will abandon the patient.
The protocol shifts to providing comfort care, which is a required and affirmative action for these patients. EMTs will still deliver supportive measures such as administering oxygen, suctioning the airway, controlling major bleeding, and giving pain medication. They will also provide emotional support to the family and contact the hospice team or the patient’s physician to coordinate further care. If the patient is not in cardiac or respiratory arrest, the DNR order does not limit treatment for other conditions, which would still receive appropriate, non-resuscitative emergency care.