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Implementation of a novel prehospital advance directive protocol in southeastern Ontario

Published online by Cambridge University Press:  21 May 2015

Rose P. Mengual ,
Michael J. Feldman  and
Gord R. Jones
Rose P. Mengual*
Affiliation:
Department of Emergency Medicine, Dalhousie University, Halifax, NS
Michael J. Feldman
Affiliation:
Division of Emergency Medicine, University of Toronto and the Sunnybrook-Osler Centre for Prehospital Care, Toronto, Ont.
Gord R. Jones
Affiliation:
Department of Emergency Medicine, Queen's University, Kingston, Ont.
*
Room 3021, Halifax Infirmary, Queen Elizabeth II Health Sciences Centre, 1796 Summer Street, Halifax NS B3H 3A7; [email protected]

Abstract

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Introduction:

Do not resuscitate (DNR) orders are commonly accepted in most health care settings, but are less widely recognized in the prehospital setting. We describe the implementation of and satisfaction with a prehospital DNR protocol that allows paramedics to honour verbal and non-standard written DNR requests.

Methods:

This prospective observational study reviewed all cardiac arrests in southeastern Ontario between March 1, 2003 and September 31, 2005. Following a verbal or non-standard written DNR request, paramedics completed a questionnaire and a follow-up structured telephone interview was conducted with surrogate decision makers (SDMs).

Results:

There were 1890 cardiac arrests during the study period, of which 86 met our inclusion criteria. Paramedic surveys were available for 82 cases (95%), and surrogate decision makers (SDMs) were successfully contacted in 50 (58%) of them. Two SDMs declined to be interviewed. The mean patient age was 72.7 (standard deviation 13.8) years and 65% were male. Sixty-three (73%) of DNR requests were verbal, and 23 (27%) were written. The mean paramedic comfort was rated 4.9 on a 5-point Likert scale (with 5 being “very comfortable” ) (95% confidence interval [CI] 4.9–5.0). The mean SDM comfort was rated by paramedics as 4.9 (95% CI 4.8 –4.9). SDMs reported comfort in withholding CPR in 47 of 48 cases (98%), and with paramedic care in all cases. One SDM stated that although it was consistent with the patient's wishes, she was uncomfortable having to make the DNR request.

Conclusions:

Satisfaction with this novel prehospital DNR protocol was uniformly high among paramedic and SDM respondents. It appears that such a protocol is feasible and acceptable for the prehospital setting. Our conclusions are limited by a small sample size, the lack of a comparison group, and limited follow-up.

Keywords

prehospital careparamedicsemergency medical servicesadvance directivesdo-not-resuscitate ordersethicscardiac arrest
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 9 , Issue 4 , July 2007 , pp. 250 - 259
Copyright
Copyright © Canadian Association of Emergency Physicians 2007

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