Implementation of a novel prehospital advance directive protocol in southeastern Ontario

Abstract

Introduction: Do not resuscitate (DNR) orders are commonly accepted in most health care settings, but are less widely recognized in the prehospital setting. We described the implementation of and statisfaction with a prehospital DNR potocol that allows paramedics to honour verbal and non-standard written DNR requests. Methods: This prospective observational study reviewed all carrdiac 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 telophone 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 succesfully 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 [C1] 4.9-5.0). The mean SDM comfort was rated by paramedics as 4.9 (95% Cl 4.8-4.9). SDMs reported comfort in withholding CPR in 47 of 48 cases (98%), and with parmedic 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 settings. Our conclusions are limited by a small sample size, the lack of a comparison group, and limited follow-up.