DNR in Emergency

1. Daily Morning Activity
Rashid A. M. Abuelhassan
R4, Emergency Medicine

2. Q.1.
• You have been called by triage a bout a 60 years male following with
palliative team as said by the son c/o fever and Decrease level of
consciousness you advised to bring him to ACC the nurse told you
that they cant get vitals .
• How you will react ?
• Will you start CPR or not ?

3. Q.2
• 70 years metastasized lung cancer, brought with decrease level of
consciousness. His EMR showing a DNR form signed 15/04/2016 no
new records in his medical records .
• What should you do?

4. Q.3
• 42, female, with breast cancer arrested at the triage . Rushed to ACC5
CPR on going a relative arrived and told you that she told him that she
don’t any one to do chest compression for her at any time of her life
and to let her die in piece.
• What shall you do?

5. Q.4
• You came to your shift in the ACC and received inducement for only
one patient how is a terminal cancer with sever sepsis and the
primary team decided to label him as DNR the form was signed by the
oncology consultant and the ER consultant only . After 5 minutes
from the beginning of your shift nurse called you saying that the
patent is pulseless .
• How would you act ?

6. Q.5
• 60 years MVC victim arrived hypotensive. He is refusing cannulation
and shouting “ let me die “
How will you react ?

7. Q.6
• 62, Male, K/C of recurrence of his thyroid cancer just came back
from a trial of chemotherapy in another country 2days back
• C/O difficulty in breathing and feeling of the discomfort on his
neck

8. • O/E: 120/m, 100/48 mmHg, RR 31/m, spO2=
88% RA , 38.1C , Hoarse voice
• sloughed, bleeding and pussy, anterior neck
wall .
• What should you do ?

9. Futile attempts Vs. poor quality of life if succeeded
Totally different from each other .
Which one deserve the name :
DNR – DNAR – DNCPR – DNACPR - AND

12. What does it mean?
• DNR = No Code
• DNR= No chest compression
• DNR = if hypotensive  No Fluids
• DNR = upper airway obstruction  no intervention
• DNR = saturation 85% on room air  no oxygen supplement
Which one is correct ?

13. What is resuscitation ?
• Resuscitation is the process of correcting physiological
disorders in an acutely unwell patient
So, What is your limits ?

14. END of LIFE thinking
• When to initiate the EOL thinking ?
• What is your limits ?

15. • Respect the dying patient’s needs for care, comfort, and compassion.
• Communicate promptly and appropriately with patients and their families about EOL care choices, avoiding
medical jargon.
• Elicit the patient’s goals for care before initiating treatment, recognizing that EOL care includes a broad range of
therapeutic and palliative options.
• Respect the wishes of dying patients including those expressed in advance directives. Assist surrogates to make
EOL care choices for patients who lack decision-making capacity, based on the patient’s own preferences,
values, and goals.
• Encourage the presence of family and friends at the patient’s bedside near the end of life, if desired by the
patient.
• Protect the privacy of patients and families near the end of life.
• Promote liaisons with individuals and organizations in order to help patients and families honor EOL cultural and
religious traditions.
• Develop skill at communicating sensitive information, including poor prognoses and the death of a loved one.
• Comply with institutional policies regarding recovery of organs for transplantation.
• Obtain informed consent from surrogates for postmortem procedures.

16. 4. Discussions regarding patient treatment preferences should be communicated to GPs,
care homes and inpatient teams to enable continuity of care and end of life care planning.
5. If a patient is at the end of life, it may be appropriate to set a ceiling of treatment in the
Emergency Department
6. Establishing a ‘do not attempt cardiopulmonary resuscitation’ order (DNACPR) should
not always limit other care given. A statement of planned active care should also be
documented where appropriate including what care should and should not be provided.
7. Patients nearing the end of life should have a resuscitation decision made before
leaving the Emergency Department and this should be appropriately documented.
8. All DNACPR decisions should be discussed with the patient’s family and the patient
unless the patient is unable to understand the decision or unless it is thought the
discussion will cause physical or psychological harm to the patient, family or carers.
9. Clinicians should be trained and able to commence medicines for symptom control. A
checklist or other end of life care documentation may be useful so that all necessary
aspects of care are considered.

17. Islam opinion ….

21. ‫أوال‬:‫اإلنعاش‬ ‫جهاز‬ ‫الستعمال‬ ‫حاجـة‬ ‫فـال‬ ‫متوفى‬ ‫وهو‬ ‫المريض‬ ‫وصل‬ ‫إذا‬.
‫ثانيا‬:‫الثقات‬ ‫المختصين‬ ‫األطباء‬ ‫من‬ ‫ثالثة‬ ‫بتقرير‬ ‫لإلنعاش‬ ‫صالحة‬ ‫غير‬ ‫المريض‬ ‫حالة‬ ‫كانت‬ ‫إذا‬-‫اإلنع‬ ‫جهاز‬ ‫الستعمال‬ ‫أيضا‬ ‫حاجة‬ ‫فال‬‫اش‬.
‫ثالثا‬:‫الثقات‬ ‫المختصين‬ ‫األطباء‬ ‫من‬ ‫ثالثة‬ ‫بشهادة‬ ‫محقق‬ ‫الموت‬ ‫وأن‬ ، ‫للعالج‬ ‫قابل‬ ‫غـير‬ ‫مستعصيا‬ ‫المريض‬ ‫مرض‬ ‫كان‬ ‫إذا‬-‫أي‬ ‫حاجة‬ ‫فال‬‫الستعمال‬ ‫ضا‬
‫اإلنعاش‬ ‫جهاز‬.
‫رابعـا‬:‫والرئتي‬ ‫القلب‬ ‫مرض‬ ‫أو‬ ، ‫متقدمة‬ ‫مرحلة‬ ‫في‬ ‫السرطان‬ ‫مرض‬ ‫أو‬ ، ‫مزمن‬ ‫مرض‬ ‫مع‬ ‫ذهني‬ ‫خمول‬ ‫حالة‬ ‫في‬ ‫أو‬ ، ‫عجز‬ ‫حالة‬ ‫في‬ ‫المريض‬ ‫كان‬ ‫إذا‬‫ن‬
‫ذلك‬ ‫الثقـات‬ ‫المختصين‬ ‫األطباء‬ ‫من‬ ‫ثالثة‬ ‫وقرر‬ ، ‫والرئتين‬ ‫القلب‬ ‫توقف‬ ‫تكرار‬ ‫مع‬ ، ‫المزمن‬-‫اإلنعاش‬ ‫جهاز‬ ‫الستعمال‬ ‫حاجة‬ ‫فال‬.
(‫رقم‬ ‫الصفحة‬:324)
‫خامسا‬:‫الثقات‬ ‫المختصين‬ ‫األطباء‬ ‫من‬ ‫ثالثة‬ ‫بتقرير‬ ‫العالج‬ ‫على‬ ‫مستعص‬ ‫الدماغ‬ ‫في‬ ‫بتلف‬ ‫اإلصابة‬ ‫على‬ ‫دليل‬ ‫المريض‬ ‫لدى‬ ‫وجد‬ ‫إذا‬-‫ف‬‫أيضا‬ ‫حاجة‬ ‫ال‬
‫ذلك‬ ‫في‬ ‫الفائدة‬ ‫لعدم‬ ، ‫اإلنعاش‬ ‫جهاز‬ ‫الستعمال‬.
‫سادسا‬:‫الثقات‬ ‫المختصين‬ ‫األطباء‬ ‫من‬ ‫ثالثة‬ ‫رأي‬ ‫حسب‬ ‫معين‬ ‫لوضع‬ ‫مالئـم‬ ‫وغير‬ ، ‫مجد‬ ‫غير‬ ‫والرئتين‬ ‫القلب‬ ‫إنعاش‬ ‫كان‬ ‫إذا‬-‫ال‬ ‫حاجـة‬ ‫فال‬‫آالت‬ ‫سـتعمال‬
‫اختصاصهم‬ ‫من‬ ‫ليس‬ ‫ذلك‬ ‫لكون‬ ، ‫رفعها‬ ‫أو‬ ‫اإلنعاش‬ ‫آالت‬ ‫وضع‬ ‫في‬ ‫المريض‬ ‫أولياء‬ ‫رأي‬ ‫إلى‬ ‫يلتفـت‬ ‫وال‬ ، ‫اإلنعـاش‬.
http://www.alifta.net/Fatawa/fatawaChapters.aspx?languagename=ar&View=Page&PageID=299&PageNo=1&BookID=16
http://www.ssfcm.org/public/arabic/Content/index/secId/37/cntId/7396/page/1/

23. DNR in the Middle East
• Jordan not recognized by
• UAE  laws forcing staff to resuscitate even if has a DNR or does not
wish to live
• Saudi Arabia  patients cannot legally sign a DNR, but DNR accepted
by order of primary physician signed by two other doctors in case of a
terminally ill patients
• Israel  Established as both primary physician and from the patient
as long as the patient is dying and aware of their actions

24. UK
England and Wales
approved If they have capacity as defined under the Mental Capacity
Act 2005 the patient may decline resuscitation OR an advance directive
• Patients and relatives cannot demand treatment (including CPR)
which the doctor believes is futile and in this situation
• If they lack capacity relatives will often be asked for their opinion out
of respect.
Scotland
• viewed by the treating clinician to be futile

25. North America
• Approved but the documentation is especially complicated in that
each state accepts different forms
• advance directives and living wills are not accepted by EMS as legally
valid forms.
• If a patient has a living will that specifies the patient requests to be
DNR but does not have a properly filled out state sponsored form that
is co-signed by a physician, EMS will attempt resuscitation.

26. Take home messages
• Palliative ≠ DNR
• DNR ≠ fluid therapy
• DNR = Chest compression
• DNR ≠ airway maneuvers if transient
• The policy of DNR differ from center to center so make sure of it
• DNR has validity check validity before considering any action
• KFMC rules is to be signed by 3 consultants and to be renewed every
6 month and that the family opinion does not change the process.

27. Communicating