Paramedics and other emergency medical personnel (EMS) are required by law to perform all the lifesaving measures they are capable of when they are called. What happens if your loved one is elderly, frail, and wants to be left in peace without any more heroic lifesaving measures? Experts say that a Living Will (Advanced Directive) is the form we all need to prevent live extending measures. Not always.

If EMS personnel are called to assist someone who is not in the hospital they must do everything they can to prevent death. Although your loved one may have given considerable thought to preparing advanced directives, these are not valid at home. This is because paramedics cannot diagnose whether a patient is terminally ill, nor do they have the time or the training to read through and interpret a possibly lengthy legal document when time is of the essence. In most states they must immediately begin resuscitation and other life saving measures unless they see a valid Out of Hospital Do Not Resuscitate Order (OOH DNR).

An Out of Hospital Do Not Resuscitate is an order from a patient's physician that is intended to insure that paramedics or other emergency personnel do not resuscitate a terminally ill patient at home against the patient's wishes. The DNR order must be completed on the form specified by the state where the emergency occurs. Each state has their own DNR forms, and most states do not recognize DNR orders from other states.

Many patients or their responsible family members make the decision to forego cardio-pulmonary resuscitation while they are patients in a hospital. They discuss this decision with their physicians, and the doctors make note of the patient's "DNR Status" in the medical chart. If they are able to leave the hospital and return home, these patients and their families often assume that their DNR status continues at home. Unfortunately, these in-hospital DNR orders do not follow the patient home, which is where the majority of sudden cardiac deaths occur. Without a Do Not Resuscitate order at home, the patient is at the mercy of any emergency professional who responds to a 911 or other emergency call.

Other patients make the decision to let nature take it's course while they are in a doctor's office, where there is no hospital chart. The doctor must then document the patient's decision to refuse resuscitation in a way that emergency responders who may be called to the patient's home can immediately recognize.

The Out of Hospital DNR order instructs emergency personnel to provide comfort care, but not to use chest compressions, artificial ventilation, or electric shocks and medication to re-start the heart or breathing. The order instructs them to make the patient as comfortable and pain-free as possible and to permit a peaceful and dignified natural dealth.

An Out of Hospital DNR is important to have in the ambulance, in the emergency room, in assisted living and in nursing homes, as well as "at home." Why in the emergency room? Because patients in the ER have not been admitted to the hospital, where DNR orders may be in the patient's chart from a previous hospitalization. The ER is considered to be "out of the hospital" for purposes of DNR orders.

If a patient has valid DNR orders, ambulance personnel are supposed to notify emergency room personnel. However, this doesn't always happen as it should. Family members should be sure to bring a copy of the patient's DNR order to the ER. You should always have at least two copies, because ambulance responders will want to have a copy with them if they are transporting the patient.

If your loved one is in the hospital, speak with the doctor about obtaining completed Out of Hospital DNR orders before you check out. Hospital doctors may be reluctant to give you an OOH DNR because they will probably not be caring for your loved one outside the hospital. If you can't get the hospital doctor to provide an OOH DNR, you must get one from your loved one's personal doctor. Some doctors are reluctant to declare a patient "Do Not Resuscitate" outside of a hospital. However, it is your elder's right to make this choice. You may have to advocate.

Most states require that an Out of Hospital Do Not Resuscitate order be completed on a particular form. You must have this form properly completed and readily available to show emergency responders if someone should call for assistance.  In many cases photocopies of the signed DNR form are sufficient. Many families post a copy of the DNR form on the door of the patient's room or on the wall above the bed. This way no one has to search for the form in an emergency, and EMS personnel can see it immediately. Many (but not all) states also issue wristbands which the patient can wear to alert all emergency personnel to their DNR status.

Each state has their own DNR rules. You cannot download a valid universal DNR document from the internet or any other source. Speak with your physician or the hospital social worker about the OOH DNR protocol in your state. Then be careful to follow the regulations about displaying and copying your completed form.

What Procedures Does an Out of Hospital DNR Allow or Disallow?

When emergency responders have confirmed that a valid OOH DNR exists, and if the patient is in full cardiac or respiratory arrest, they will NOT

Do CPR
Use mouth-to-mouth or other artificial ventilation (breathing)
Insert breathing tubes
Use a defibrillator
Administer resuscitation drugs

If the patient's heart is still beating and he is still breathing, emergency responders will usually transport the patient to the hospital while providing as much comfort care as possible. They will usually:

Administer oxygen
Remove anything from the airway that might be obstructing breathing
Apply splints, bandages or other first aid and control any bleeding
Start an IV
Give emotional support

What if the Patient Changes His or Her Mind About Being DNR?

Do Not Resuscitate orders can be revoked at any time. If your elder is able to make these decisions, he or she can at any time remove a DNR bracelet and destroy the DNR form. If he or she is still able to speak when paramedics arrive, a simple verbal statement that resuscitation is desired is sufficient. Paramedics will do all that they can if the patient tells them that is their desire.

If the patient is not able to speak, the legally responsible family member can remove the bracelet and destroy the DNR document.* If you are tempted to do this, please give serious thought to what your elder would have wanted if he or she could speak. According to recent statistics, less than 2% of seniors survive full cardio-pulmonary resuscitation measures for longer than a week, and most die in extreme pain.

*Check with the attorney who prepared your legal documents about your authority to make these decisions.