Question about No Resuscitate Orders and Advanced Directives

[themilesfamily]

I have a question for someone who knows how these work.

Recently my mother-in-law began choking in the home. Her husband called the ambulance and by the time they got there she was unconscious. (Her husband said that she had been unconscious for only a minute or two.)

He said that when the ambulance arrived the paramedics pulled out her advanced directive/no-resuscitate-order -- supposedly they had this with them . They said she didn't want to be resuscitated and said that they couldn't treat her. Her husband said that he had to convince the paramedics to resuscitate her. Due to the delay, she is now in a vegetative state brought on by no oxygen to the brain.

Here's what doesn't make sense to me:
1) Why would the paramedics/ambulance driver have had a copy of the order with them to pull out and show the husband? (He says they actually pulled out a hard copy and showed it to him.) When paramedics are responding to a choking emergency, would they actually take time at the hospital to pull out a hard copy of someone's advance directives before they leave?
2) I can't imagine "no-resuscitate" applies to someone who just passed out from choking.

Can anyone shed some light on this? The story just doesn't make sense to me.

 

[Forevryoung]

Unfortunately, a DNR (do-not-resuscitate order) DOES prohibit first responders from acting in a certain manner. I'm an EMT, we don't carry advanced directives or DNR's- that's up to the family/patient to provide at the time of our arrival.

While they could have attempted to dislodge the item she was choking on, they could not intubate (to provide oxygen) or shock with a defibrillator even if her heart stopped due to lack of oxygen because of the obstruction.

I've witnessed a woman with cancer die because her tracheotomy was clogged and we couldn't clear it fast enough before her heart stopped. We literally watched her die and there was no longer anything we could do. And her cause of death wasn't because of the cancer but because she couldn't breath. It was very sad.

I'm sorry.

 

[wdwfan16]

I am surprised you FIL did not know of the directive. It seems off the EMTs had a hard copy. How did he convince them to go against the DNR?

DH and I have a medical directive but each of us is the only person who has the copy. When I went for surgery they asked if I had one. I said yes. They did not ask me to produce it. We did discuss how far they were to go if something when wrong.

 

[bumbershoot]

Was there another relative there who might have given it to them without your FIL (or step FIL since you called him her husband) knowing? Was she choking ON something and they did nothing? That doesn't seem right...just b/c I might have such an order doesn't mean they shouldn't treat me if I'm bleeding, so you'd think they should be able to clear an obstruction without it being considered resuscitating a person. Right?

I'm so sorry that this has happened. And you're right, it doesn't really make sense.

 

[chicagoshannon]

That was WRONG of the paramedics. They should have tried to dislodge whatever she was choking on. A DNR means CPR couldn't be perfomed but they are to still TREAT her.

I used to worn in a nursing home and one of the other homes that was owned by the same company did the same thing the paramedics did. They were sued and the family won the lawsuit.

 

[TinkerbEllnor]

I am a nurse and just recently renewed my CPR Basic Lifesaving course. One of the changes they have made since the last time I took the class had to do with how to treat a choking victim.

If the person is conscious, they do the Heimlich. But once the person goes unconscious, instead of straddling the person and continuing the abdominal thrusts to try to dislodge the item, they proceed directly to CPR- chest compressions and rescue breaths- regardless of if their heart is still beating or not.

If she had a DNR, they wouldn't be able to do CPR. But I agree that it is pretty weird that the EMTs had a copy with them already.

 

[MomRN]

A DNR menas do not resuscitate, not do not treat. Was she already gone when they arrived or did they have to bring her back? If she was already dead (no pulse, no respirations) then the the paramedics were right. If she still had a heartbeat, then they should have attempted to remove the foreign object from her airway.

I don't know about paramedics having DNR/advance directive orders. I'm sure different states have different statues. Our paramedics don't have that information with them.

I'm sorry for you having to go through this. If she is in a vegetative state did her advance directives refuse artificial nutrition and fluids?

 

[Pea-n-Me]

Just trying to understand the details of the story. Does MIL have a chronic illness or condition? Has she frequently and/or recently been transported to the hospital by this ambulance company (ie did they "know" her)? Did she acutally have a DNR directive in place at the time of this incident?

 

[bumbershoot]

But once the person goes unconscious, instead of straddling the person and continuing the abdominal thrusts to try to dislodge the item, they proceed directly to CPR- chest compressions and rescue breaths- regardless of if their heart is still beating or not.

If she had a DNR, they wouldn't be able to do CPR. But I agree that it is pretty weird that the EMTs had a copy with them already.

But wouldn't that cause a bigger problem with the item the person was choking on???

If all this happened how the OP's MIL's husband (to write it like she did) said it did...could the EMTs gotten somehow confused with doing CPR things in order to help someone choking VS doing CPR to actually bring a person back?

And...if a person's heart is beating it seems bizarre that they would do chest compressions...what exactly is all of that doing for someone choking ON something???

 

[themilesfamily]

Was there another relative there who might have given it to them without your FIL (or step FIL since you called him her husband) knowing?

MIL and FIL were the only ones home.

As to what happened that night -- FIL said that he was giving MIL suppositories because she was feeling nauseated. (He supervised all her medication -- he kept her meds and distributed them to her as she needed it -- she was on Oxycontin for fibromyalgia and a couple of other meds.) She began vomiting and he said that she started to choke on her vomit and passed out. He called 911 -- he said she had only been unconscious a minute or two before they arrived. When they showed up they stuck a hard copy of the advanced directive in his face and said they wouldn't treat her. He argued with them to treat her. This caused a delay and now she is in a vegetative state in the hospital due to the delay in getting oxygen to her brain.

FIL claims that he didn't produce the directive or even mention it -- he insists that the ambulance driver/paramedic had a hard copy and produced it and refused to treat her, thus causing the delay that caused the brain damage.

I just don't see how some random ambulance would have had a hard copy of this woman's directive with them that would have caused this problem in the first place.

I don't know. Somehow this just isn't adding up for me.

Regardless, FIL has now taken MIL off all life-support and they are withholding food and water, so she will pass soon I suppose. It's incredibly sad. MIL was a saint and FIL -- not so much.

 

[themilesfamily]

Was she already gone when they arrived or did they have to bring her back? If she was already dead (no pulse, no respirations) then the the paramedics were right. If she still had a heartbeat, then they should have attempted to remove the foreign object from her airway.

She still had a heartbeat and pulse. And the doctor said, in the hospital, that her heart is still beating very strong.

But her directive said that she doesn't want to live in a vegetative state, so they are refusing nutrition and fluids and other care at this point.

There is little brain activity.

ETA: MIL is 67. She was 100% okay mentally. Physically she'd had fibromyalgia for some years and had been taking a lot of Oxycontin. My DH (her son) really encouraged her to cut down on that and DH was told that she had been cutting back slowly per her doctor's orders.

 

[TinkerbEllnor]

But wouldn't that cause a bigger problem with the item the person was choking on???

If all this happened how the OP's MIL's husband (to write it like she did) said it did...could the EMTs gotten somehow confused with doing CPR things in order to help someone choking VS doing CPR to actually bring a person back?

And...if a person's heart is beating it seems bizarre that they would do chest compressions...what exactly is all of that doing for someone choking ON something???

I asked that at the class, as it went against what I found logical as well. I did not get a satisfactory answer- just that they were trying to simpify the process so more good samaritans would be able to remember the steps and be willing to step in. Just keeping it going until EMTs could arrive to intubate- which if they had a DNR they wouldn't be allowed to do.

to OP

 

[bumbershoot]

Thank you for the reply, TinkerbEllnor, I really appreciate that.


And yes, a few more to the OP and her family.

 

[heatherwillmom]

I am a Primary Care Provider. I used to be a Hospitalist at a nursing home. I have explained to many relatives that DNR does not mean Do Not Treat. I am not sure how the EMS had a copy of her advance directives unless she had provided a copy in the past. I have heard of patients giving a copy to the office of the EMS for future use. I cannot understand, however, why they took the time to go to the office & check for the paper before they responded to an emergency. This is something that as a PCP, I almost never say, but I think I would consult legal help.

 

[mickeyboat]

That makes absolutely no sense to me. I don't understand how that paramedics would have known she had a DNR. And why would they refuse treatment if her heart was still beating?

My FIL had a DNR and signed it once he was diagnosed with terminal cancer and decided to discontinue palliative treatment. He received a bracelet to wear so that emergency responders would know he had a DNR, but the paramedics did not have a copy.

Sounds really fishy to me.

I am sorry for what your family is going through.

 

[Judy from Boise]

If it makes you feel better this was not a "choking" episode, but an aspiration. Vomitus would not have been dislodged with the heimlich maneuver, it would require suctioning.....now why the EMTs chose not to suction I can't know without hearing their side of the story.

 

[C.Ann]

MIL and FIL were the only ones home.

As to what happened that night -- FIL said that he was giving MIL suppositories because she was feeling nauseated. (He supervised all her medication -- he kept her meds and distributed them to her as she needed it -- she was on Oxycontin for fibromyalgia and a couple of other meds.) She began vomiting and he said that she started to choke on her vomit and passed out. He called 911 -- he said she had only been unconscious a minute or two before they arrived. When they showed up they stuck a hard copy of the advanced directive in his face and said they wouldn't treat her. He argued with them to treat her. This caused a delay and now she is in a vegetative state in the hospital due to the delay in getting oxygen to her brain.

FIL claims that he didn't produce the directive or even mention it -- he insists that the ambulance driver/paramedic had a hard copy and produced it and refused to treat her, thus causing the delay that caused the brain damage.

I just don't see how some random ambulance would have had a hard copy of this woman's directive with them that would have caused this problem in the first place.

I don't know. Somehow this just isn't adding up for me.

Regardless, FIL has now taken MIL off all life-support and they are withholding food and water, so she will pass soon I suppose. It's incredibly sad. MIL was a saint and FIL -- not so much.

She was on oxycontin for fibromyalgia? That's a very potent narcotic - not to mention extremely addictive.. Are you sure she didn't have some other serious illness that was being kept from the rest of the family?

It's a shame that you all have to go through this.. Hopefully she will pass peacefully and quickly..

 

[themilesfamily]

If it makes you feel better this was not a "choking" episode, but an aspiration. Vomitus would not have been dislodged with the heimlich maneuver, it would require suctioning.....now why the EMTs chose not to suction I can't know without hearing their side of the story.

You're right. It was aspiration. The dad described her as "choking" on her own vomit -- but she actually aspirated it.

As to the oxycontin for fibromyalgia -- she didn't have any medical condition that I know of that would warrant such a powerful narcotic other than the fibromyalgia -- and that's why the family said she took it. I can only go by what FIL said because he's the one who supervised anything medical for her -- meds, doctor appointments, etc.

My husband talked to his dad numerous times about getting MIL off of oxycontin, but FIL was resistant -- he said that's what the doctors wanted her on. Eventually DH threatened to call her doctor himself and express his concerns, and at that point FIL said they started cutting her oxycontin levels down.

 

[themilesfamily]

It's a shame that you all have to go through this.. Hopefully she will pass peacefully and quickly..[/B]

Thank you C.Ann. You have always been such a kind person on these boards. I really appreciate it.

And thank you to everyone else who commented and expressed your condolences. My MIL is a very caring woman -- and very young -- it's hard to see her go.

 

[Abbie]

You're right. It was aspiration. The dad described her as "choking" on her own vomit -- but she actually aspirated it.

As to the oxycontin for fibromyalgia -- she didn't have any medical condition that I know of that would warrant such a powerful narcotic other than the fibromyalgia -- and that's why the family said she took it. I can only go by what FIL said because he's the one who supervised anything medical for her -- meds, doctor appointments, etc.

My husband talked to his dad numerous times about getting MIL off of oxycontin, but FIL was resistant -- he said that's what the doctors wanted her on. Eventually DH threatened to call her doctor himself and express his concerns, and at that point FIL said they started cutting her oxycontin levels down.

I'm so very sorry your family is going through this, I hope your MIL passes peacefully.

Do you have any concerns about your FIL maybe not being truthful about any of this? The fact that he had control of her meds and only backed off when your DH threatened to check up on him seems very odd behavior.