NH Do Not Resuscitate (DNR) Orders & Advanced Directives

8.7 Do Not Resuscitate (DNR) Orders& Advanced Directives



 Recognized DNR Options in New Hampshire
1. The following are the only recognized DNR options in New Hampshire: “P-DNR” (portable DNR) order: statewide recognized document of any color and/or a “DNR” (Portable DNR) wallet card signed by a physician or APRN
2. Medical orders form documenting the patient’s name and signed by a physician or APRN and
that clearly documents the DNR order. 3. DNR bracelet or necklace worn by a patient, inscribed with the patient’s name, date of birth (in
numerical form), and “NH DNR” or “NH Do not resuscitate.” Note: Under state law, a DNR bracelet or necklace may only be issued to patients who have a
valid DNR order. Note: Neither a Living will or a Durable Power of Attorney for Healthcare (DPOAH) form is as
effective as a valid DNR order. A patient’s healthcare agent under a DPOAH may not direct EMS
providers to withhold resuscitation in the absence of a valid DNR Order.

When a written DNR order is not available and a DPOAH is present and requests that
resuscitation be withheld, contact online Medical Control for guidance. For patients present or residing In a healthcare facility, the following is also acceptable
A DNR order written by a physician or APRN at a nursing home, hospital, or other healthcare
facility issued in accordance with the healthcare facility’s policies and procedures. For Patients Being Transferred
All forms of DNR identified above remain valid during a tran
Do Not Resuscitate (DNR) Orders
& Advanced Directives
The New Hampshire Bureau of EMS has taken extreme caution to ensure all information is accurate and in accordance with professional standards in effect at the time of publication. These protocols, policies, or procedures MAY NOT BE altered or modified.
Procedures not to be Performed
If there is a valid DNR order and the patient is in cardiac or respiratory arrest, or cardiac or
respiratory arrest is imminent, EMS providers should withhold the following procedures:
Do not perform chest compressions or actively assist ventilations via BVM. Do not intubate or place advanced airway devices. Do not defibrillate. Do not administer resuscitation drugs to treat cardiac arrest or the rhythms identified below:
o Ventricular fibrillation, o Pulseless ventricular tachycardia, o Pulseless electrical activity
o Asystole. Procedures that may be performed
If the patient is not in imminent cardiac or respiratory arrest, and has a valid DNR order
appropriate medical treatment for all injuries, pain, difficult or insufficient breathing, hemorrhage, and/or other medical conditions must be provided. EMS providers MAY perform any other measures, including comfort measures, for these
patients, within their scope of practice per the usual treatment guidelines, including but not limited
to:
Oxygen therapy via nasal cannula, non-rebreather mask, and/or CPAP. Medications for treatment of pain, respiratory distress, dysrhythmias (except for those
identified above). Intravenous fluid therapy for medication access. Mouth or airway suctioning. NH statutory DNR Form
Do not resuscitate Order. As attending physician or APRN of [patient’s name here] and as a licensed physician or
advanced practice registered nurse, I order that this person SHALL NOT BE Resuscitated in
the event of cardiac or respiratory arrest. This order has been discussed with [patient’s name here] (or, if applicable, with his/her agent,)
[name of DPOAH], who has given consent as evidenced by his/her signature below. Attending physician or APRN name:________________________________________________ Attending physician or APRN signature:_____________________________________________ Address:______________________________________________________________________ Patient signature:_______________________________________________________________ Address:______________________________________________________________________ Agent signature (if applicable):_____________________________________________________ Address: _____________________________________________________________________
Policy Continued
Policy Continues
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8.7
2013
8.7
Do Not Resuscitate (DNR) Orders
& Advanced Directives
P
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8.7
The New Hampshire Bureau of EMS has taken extreme caution to ensure all information is accurate and in accordance with professional standards in effect at the time of publication. These protocols, policies, or procedures MAY NOT BE altered or modified.
Durable Power of Attorney for Healthcare
Under a Durable power of attorney for healthcare, a patient may designate another person—a
healthcare agent—to make health care decisions for the themselves. Before a healthcare agent may make decisions on behalf of the patient, the patient’s attending
physician or APRN must certify in writing that the patient lacks capacity (this certification is
filed within the patient’s medical record). A patient who, in the clinical judgment of the EMS provider, retains the capacity to make
health care decisions, shall direct his or her health care, even where a healthcare agent has
been appointed. That is, EMS providers shall follow the wishes of the patient rather than the
healthcare agent unless the patient lacks the capacity to make health care decisions. The healthcare agent must make an informed decision. It is generally advisable for EMS
providers to perform at least a preliminary assessment and inform the healthcare agent of the
options for caring for the patient. Note: in the absence of a valid DNR order, a healthcare agent does not have the
authority to direct prehospital providers to withhold resuscitation in the event of a
cardiac arrest. When a written DNR order is not available and a DPOAH is present
and requests that resuscitation be withheld, contact online Medical Control for
guidance. Living Will
A living will is intended to address patients who have been admitted to a healthcare facility. Living
wills will rarely, if ever, have application in the prehospital environment. POLST (Provider Orders for Life-Sustaining Treatment)
When confronted with a seriously ill patient who is not in cardiac arrest and a POLST form (yellow
form), see POLST Appendix A4 is available, utilize as follows:
Section B
Full Treatment box is checked: Use all appropriate measures to stabilize/resuscitate patient. Limited Interventions box is checked: The maximum airway interventions are non-rebreather
mask, CPAP, and suctioning. All appropriate IV medications may be utilized. No electrical
therapies are to be provided. Comfort-focused Care box is checked: The maximum airway interventions are non-rebreather
mask, suctioning and treatment of airway obstruction, as needed. Medications to relieve pain
or discomfort. Note: Section C refers to IV therapy for hydration and nutrition. Advanced EMTs and Paramedics
may start an IV for the purpose of medication administration outlined in Section B.
Policy Continued
PEARLS:
You must have a valid DNR order or DNR jewelry. Neither a Durable Power of Attorney or a
Living Will may be treated as a DNR order. Neither a spouse nor a healthcare agent / durable power of attorney may direct you not to
perform resuscitation unless the patient has a valid DNR order. Your decision to withhold resuscitation is protected under the New Hampshire DNR law as
long as it is based on the good faith belief that you have been presented with a valid DNR
order or DNR jewelry.