Compelling Reasons

At our regional medical advisory committee’s meeting last week I listed a number of issues I wanted us to address when we reconvened in the fall, including changing our state’s DNR regulations to enable paramedics to accept a family’s verbal wishes not to initiate resuscitation in a patient with a terminal condition in cardiac arrest. I will be giving a presentation on the proposal in September.

This proposal is the “Compelling Reasons” protocol initiated in King Country, Washington.

I have written about this in previous entries:

DNR Study Results

Here is a direct link to the King County study:

Futile Resuscitations

Withholding Prehospital Resuscitation: A New Approach to Prehospital End of Life Decisions (Full Study Text)

Withholding Prehospital Resuscitation (Editorial)


Today I had a ninety-seven year old man found in his bed by his daughter not breathing. She had previously seen him alive an hour before. It was hot in the room and the patient was still warm with no rigor or lividity. As I put the pads on(which showed asystole), I asked the daughter if her father had any DNR orders. She replied he did in the nursing home, but they had expired. I asked what her wishes for resuscitation were? She said his wishes were that he not be resuscitated. I had my crew start basic CPR and then I called the hospital and spoke with a doctor who gave me permission to presume the patient dead without having to initiate ACLS. The daughter was already on the phone calling her brothers and sisters to tell them their father had died.

This scene could have played out any number of ways. The family member could have said she wanted the father to be resuscitated, I could have simply chosen to work the patient on my own lacking a current DNR, intubated him, and put in an IV and done 20 minutes of ACLS before presuming him dead, or when I did call for permission to presume, the doctor could have told me to work the patient doing full ACLS and transport.

All in all I thought it worked out all right. A 97 year old dead, curled on his side in his own bed, in the house (I found out) he had lived most of his life and raised his family in.


My preceptee was cut loose last week. We never did get a cardiac arrest. I wonder how I would have handled the call if she were still with me. Finally, getting the code, the warm body to prove her skills on.

I wrote about a similar situation last summer in Practice.


  • Anonymous says:

    i have a pretty big fear that i will not start cpr on someone i should have, or that i will withhold thinking they are too far gone…

  • Loving Annie says:

    It would be awesome if EVERY state enabled paramedics to accept a verbal DNR from a family.I dread the idea of being worked on if I am dead. Let me go with dignity, in peace, and without a ton of unnnecesary bills for my family to deal with.

  • Anonymous says:

    The service I’m doing my paramedic student time with has allowed us to call, explai a situation like this and not start the code. I would hope to that it would be a broad range thing that everyone had the chance to do because beating up a dead body is just a waste of time and emotion on everyone.

  • Anonymous says:

    The larger issue is with society. When people see their elderly parent or relative quit breathing or find them unresponsive first thing in the morning, they really need to understand that calling 911 and summoning EMS may not be the best thing. EMS, in these cases of the terminally ill with no DNR, is like a Doomsday machine. Once the Doomsday machine is activated, it cannot be stopped. There are protocols that must be followed, procedures that must be undertaken.As much as I wish I didn’t have to work codes that are obviously futile, in cases where there is no DNR and the family voices that the patient did not want ACLS care, I will begin my process whether they like it or not. Yes, I will call on-line medical control, and ask, but if I can’t get in touch with them, I will begin the resuscitation. If there are 100 people watching, and 1 says, “She changed her mind! She wanted to live.” The minority opinion carries the day. Resuscitation will begin.I just can’t put my job, license, professional reputation, or the ambulance company at risk in these situations. It sucks. I hate it. I would like nothing better than to be able to NOT work a code. But I can’t. I’ve worked codes on obviously dead people, people for whom there is zero hope for survival because protocol mandated I do it. I’ve transported zero-hope codes to the hospital red lights and sirens when I knew the physican would call it right there in the ER, patient still on our cot because I had to. I knew what would happen the second I walked in the house, and what would unfold every step of the way.Sometimes I walk into a house and just get the feeling like if I don’t work the code, that there will be some sort of civil litigtaion involving me. So I work it because I know too many people that have been sued for stupid stuff. The last thing I want is to be deposed in a court case and have to defend why I didn’t do something when, even if it was in the patient’s worst interest, it was in my best interest to do something.A lot of patients and families are looking for someone to blame. These people are ticking time bombs. I can’t afford to take that risk, no matter how awful it is.

  • PC says:

    This is a touchy area frought with pitfalls. Its hard to make a policy that covers every case.One commenter said they had a fear of not starting CPR on someone they should have — the fear I have now is under our cessation of ALS recusitaion, we can work an asystole patient for 20 minutes and then call them if we get no change, but I have had instances and I know other people have where they work these people and then you toss in the drugs, good CPR and just when you are ready to call them, the drugs kick in and you have a living dead body. I know one medic who called the patient after 20 minutes only to see the monitor start to show a rythmn after the resucsitation ended. I have been in the position of that person coming back just as I was ready to call it. I am actually more comfortable leaving a warm body (such as a 95 year old terminal cancer patient with asystole) than leaving a 95 year old terminal cancer patient who I have pumped with epi for 20 minutes to no avail (yet).

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