CODE STATUS FACTS
What is an "Attempt CPR" Code Status as indicated on the MOLST form?
Full Code (do CPR & intubation).
What are the three valid MOLST/DNR Orders accepted by Maryland?
Signed MOLST form (signed by a physician, PA, or NP)
MOLST bracelet with insert
Authorized metal emblem (the star of life)
Which code status is always dispatched BLS?
DNR-B Palliative Care
True or false: EMS Clinicians can transport patients to an inpatient hospice facility in lieu of an emergency department
True. Can call miemss office to get the list of facilities (410-706-4367 (4DNR)), or consult with EMRC to request inpatient hospice facilities status.
You are part of a crew called out to a home where CPR is in progress. You arrive on scene to find an elderly gentleman lying on the floor. Family members have started CPR. A family member hands you a signed DNR/MOLST form that has option B selected. What would you do any why?
Stop CPR and resuscitation efforts. Confirm the patient is pulseless and breathless. Notify communications to obtain the time of death, and then have a conversation with the family about the patient's wishes as indicated on their valid MOLST form.
What is option A1 and what does it mean?
Comprehensive efforts prior to arrest INCLUDING intubation, then DNR. Intubation is okay prior to arrest.
True or False: A copy of the MOLST/DNR form is an acceptable DNR order
True. Electronic copies on a device/computer are also acceptable as long as they are contained within an EHR/patient care device (ie at a facility).
What methods can you use to open the airway of a DNR-B patient in respiratory distress?
Noninvasive means (e.g., chin lift, jaw thrust, NPA, OPA, Heimlich maneuver, or laryngoscopy with Magill forceps for suspected airway obstruction).
Who can revoke a DNR order and how?
The patient, physician, or authorized decision maker can physically destroy or cancel DNR devices/forms.
The patient can orally revoke by stating to EMS that they want only palliative care or resuscitation.
You are part of a crew that finds a patient sitting in his living room clutching his chest. His wife states that he is a DNR and presents you with a valid MOLST form. At this point, the patient states that he wants to do everything to save his life if he goes into cardiac arrest. What would you do?
Treat this as the patient orally revoking his DNR order and provide full resuscitation efforts if he goes into cardiac arrest. This is a one-time revocation of the order and not a permanent change in code status. Document (and get witness signatures)!
What is DNR-B Palliative Care Code Status & what does it mean?
Palliative/supportive care prior to arrest, no intubation, DNR/DNI
What oral DNR orders can be followed?
An oral EMS/DNR Order directly from a Maryland licensed physician (MD or DO), physician assistant, or nurse practitioner who is physically present “on-site" or via on-line medical direction via EMRC.
EMS cannot accept orders from private physicians, PAs, or NPs by telephone.
Can ALS give dextrose to a patient having a diabetic emergency who is DNR-Option A2? What should they do if this patient arrests?
Yes they can! If the patient arrests, the patient should not be resuscitated or intubated. This patient should not be intubated prior to arrest as well.
True or false: You are allowed to contact the physician, PA, or NP that signed the patient's DNR order or contact the patient's hospice program for clarifying questions on the patient's code status.
True! Oral orders over the phone about what to do for treatment cannot be accepted via telephone however.
You are part of a crew that has been called to a local gas station for an elderly female complaining of chest pain. You arrive on scene and find the female sitting in the back seat of the car. Her family presents you a DNR form from out of state. It is easy to understand but it has diff options.
Follow the directives on the form, as signed out of state DNR orders are valid. Provide treatment as required for the patient's current condition.
What is Option A2 and what does it mean?
Comprehensive efforts prior to arrest, EXCEPT intubation, then DNR. DNR/DNI
Name five examples of unacceptable DNR orders
Advanced directives without EMS DNR order, Facility-specific DNR order, Notes in medical records, Prescription pad orders, DNR stickers, Oral request from someone other than a physician, PA, NP, Oral order from attending physician, PA, NP who is not on-site (or through EMRC)
a). Can you administer oxygen to a DNR-B patient in respiratory distress? If so, how/by what means?
b). What do you do if a DNR-B patient is found to be on a ventilator at an outpatient facility and is in cardiac arrest?
a). Nasal cannula or nonrebreather mask.
b). Contact on-line medical direction about disconnecting the ventilator.
What do you need to document in your narrative for the DNR/MOSLT protocol?
Who gave you the EMS/DNR Order or MOLST form or where the EMS/DNR Order or MOLST form was found and at what time. The EMS/DNR Order number, the effective date of the order, the name of the patient, the patient’s date of birth, and the name of the physician, NP, or PA that signed the MOLST.
Can an advanced directive be used in place of a MOLST form?
No. Advanced directives without a MOLST/DNR order cannot be used and are not valid.
What are five examples of the acceptable treatments that fall under "comprehensive care prior to arrest" for options A1 and A2?
Continuous Positive Airway Pressure (CPAP), cardiac monitoring, synchronized cardioversion for pulse present ventricular or supraventricular tachycardia, cardiac pacing for pulse present symptomatic bradycardia, insertion of IVs, and drug therapy
Where should you anticipate finding DNR orders? (5 answers)
About a patient’s wrist, hung from a necklace, or safety-pinned to a patient’s clothing. At medical facilities, in the patient’s chart. In residences and domicile facilities, by the bedside, behind the patient’s bedroom door, or on the refrigerator door. In schools and educational institutions
What can be done for a DNR-B patient in severe and uncontrolled pain?
Family or caregivers can administer patient's medications, PCA (Patient controlled analgesia) devices should remain intact.
For significant pain or prolonged transport, can initiate pain control protocol (BLS - acetaminophen, ALS - Fentanyl, Ketamine, Ketorolac, Morphine).
What do you do if an EMS/DNR bracelet is found detached from the patient?
EMS personnel must treat it as an EMS/DNR Order form and identify the subject of the EMS/DNR Order as the patient. A valid bracelet insert alone, without the vinyl bracelet, is a valid EMS/DNR Order so long as EMS clinicians confirm the patient’s identity.
You are called to the local nursing home for a patient having difficulty breathing. You arrive on scene and find the patient sitting in his wheelchair working hard to get his breath. His wife has been visiting him and is there with him now. The nursing home staff state that he is a DNR patient. In between breaths, the patient states that he doesn’t want to die. The wife states she is his authorized healthcare decision maker and that the patient has severe dementia. What is your legal obligation here?