With today’s question we revisit the issue of DNR orders and first aid:

My question is about DNR orders in an emergency situation. One of our Fire service teams attended a cardiac arrest recently. At the time of the cardiac arrest a DNR order was not present, but a member of the public advised our team that a DNR order was in place. Where does a first responder stand in this situation? If a family member is present, do we take this as valid in an emergency situation for first responders.

I have addressed these issues in a number of posts – see

The key issue is that the justification for treating someone who cannot communicate their wishes (including someone in cardiac arrest) is the common law doctrine of necessity – see

Lord Goff in In Re F [1990] 2 AC 1 said (emphasis added):

The basic requirements, applicable in these cases of necessity, that, to fall within the principle, not only (1) must there be a necessity to act when it is not practicable to communicate with the assisted person, but also (2) the action taken must be such as a reasonable person would in all the circumstance take, acting in the best interests of the assisted person.

On this statement of principle, I wish to observe that officious intervention cannot be justified by the principle of necessity. So intervention cannot be justified when another more appropriate person is available and willing to act; nor can it be justified when it is contrary to the known wishes of the assisted person, to the extent that he is capable of rationally forming such a wish.

The important phrase is ‘known wishes’ of the patient.  Being advised by ‘a member of the public … that a DNR order was in place’ would not be sufficient to give anyone confidence that they were being informed of the patient’s wishes.  The ‘member of the public’ would need to be interrogated as to who they are, how they claim to know this, what they know of the patient etc. That is not a process anyone could go through where time is of the essence and will be an issue for the hospital assuming the patient makes it to hospital.

But where the responding crew are advised by someone clearly identified as the ‘person responsible’ (eg the patient’s spouse where there is no doubt that they are indeed the spouse) and there is evidence that lends weight to what they are saying – eg the person is in cardiac arrest in a room that has the equipment and drugs to indicate they were receiving end of life care, then the crew may be more confident in what they are being told.

Conclusion

Applying the law in the particular circumstances of a cardiac arrest does not allow time to fully investigate the patient’s wishes.  First responders would be well advised, particularly if they are a fire service responding to a triple zero call, to commence CPR as making the decision to withhold treatment is better left to paramedics or hospital staff.  Where however there is a sufficient degree of satisfaction that the patient has indicated that they do not want CPR (as discussed in the post Listening to the patient’s family (June 2, 2022)) then the patient’s known wishes should be respected.

In the circumstances described there would be almost no chance of legal liability for continuing CPR as a fire fighter could not reasonably determine what the patient’s wishes were. The ‘reasonable’ response, given someone was sufficiently motivated to ring triple zero, would be to commence CPR and, except in the most clear cut cases, leave the hard choices to the medical professionals.

This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.