Massachusetts Advance Directives – What is the Law? Part 1 of 3

There is much confusion and misunderstanding about the various types of Advanced Directives, Medical Orders and when each can or cannot be used. This article will attempt to identify and define the various types of Advanced Directives currently in use in Massachusetts and help the reader understand their options when considering advance directives for themselves or loved ones.

Advanced Directives and Medical Orders

1. Do not resuscitate (DNR) orders – in-hospital.
2. Comfort Care DNR verification form – out-of-hospital.
3. Health Care Proxy (HCP) and Living Wills.
4. Medical Orders for Life-Sustaining Treatment (MOLST).

DNR Orders

1. Do not resuscitate (DNR) orders are medical orders issued by an attending physician in a hospital setting after the doctor consults with the patient to ensure the patient (or his guardian/HCP) is aware of the consequences of the order.
2. DNR orders address the use of extra-ordinary efforts, cardiopulmonary resuscitation (CPR), intubation, artificial ventilation, cardiac resuscitation with drugs and defibrillation, in order to keep patients alive when they experience life threatening medical conditions.
3. DNR orders are only valid in the facility where they are issued.
4. Once the person leaves the facility, the DNR order is no longer valid.

When a patient is in a non-hospital setting, Emergency Medical Technicians (EMTs) are required to provide emergency medical care and to transport patients to appropriate health care facilities. Emergency Medical Services (EMS) personnel are required by law to provide treatment to the fullest extent possible, subject to their level of training.

Comfort Care DNR Order Verification Protocol (Comfort and Care DNR)

1. The Comfort Care DNR is designed to allow EMTs and first responders to honor a DNR order in an out-of-hospital setting.
2. Before 1999, when Massachusetts implemented its Comfort Care DNR protocol, there was no mechanism to enable EMT’s and other first responders to recognize DNR orders in a non-hospital setting. So EMT personnel were always obligated to perform full resuscitation measures when they encountered a patient unable to convey directions regarding medical treatment.
3. The Comfort Care DNR protocol provides for a statewide, uniform DNR verification protocol.
4. The purpose of the Comfort Care DNR is to: (a) provide a verification of DNR orders to enable EMTs and first responders to honor DNR orders, (b) clarify the role and responsibilities of EMTs and first responders at the scene and/or during transport of patients who have a valid current DNR order, (c) avoid resuscitation of patients who have a current and valid DNR, (d) provide for palliative/comfort care measures for patients with a current Comfort Care DNR order verification form.
5. Comfort Care DNR order verification forms must be completed and signed by the patient’s physician, authorized Physician’s Assistant or Nurse Practitioner.
6. The patient must post the Comfort Care DNR where any EMT or first responder can easily find it. (Usually the patient’s refrigerator, or taped to the patients bedroom door. The Department of Public Health stopped issuing Comfort Care DNR bracelets in 2007, but the Department’s approved form contains bracelet inserts that can be used in generic wrist bracelets.
7. The Comfort Care DNR Order Verification form can be accessed by anyone, in downloadable format from the Massachusetts Department of Public Health/Office of Emergency Medical Services website, at: http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/oems/comfort-care/public-health-oems-comfort-care-verification.html. But the form must be fully completed and signed by the attending physician, authorized nurse practitioner or authorized physician assistant as proscribed by the regulations.

Upon confirmation of a current/valid Comfort Care DNR Order Verification Form:

If the patient’s heartbeat and breathing are adequate, but there is some other emergency illness or injury, the EMS personnel shall provide full treatment and transport as appropriate.

If the patient is in full cardiac or respiratory arrest, the EMS shall not resuscitate, which means they will not:

• Initiate CPR;
• insert an oropharyngeal airway
• provide ventilator assistance
• artificially ventilate the patient
• administer chest compressions
• initiate advance airway measures such as intubation
• administer cardiac resuscitation drugs
• defibrillate.

If the patient is not in full respiratory or cardiac arrest, but the patient’s heart beat or breathing is inadequate, EMS personnel shall not resuscitate but shall provide:

• emotional support
• suction airway
• administer oxygen
• application of cardiac monitor
• control bleeding
• splint
• position for comfort
• initiate IV line, and
• contact Medical Control, for further orders, including medication.

If EMS personnel have any question regarding the validity or applicability of the Comfort Care DNR, the EMS personnel shall:

• verify with the patient, if the patient is able to respond
• provide full treatment
• contact Medical Control for further orders.

EMS personnel are not to honor any Comfort Care DNR where the form is void or not intact. A patient may revoke their valid Comfort Care DNR at any time, regardless of mental or physical condition by the destruction or affirmative revocation of the Comfort Care DNR.

If an individual identifying him/herself as the health care agent or guardian revokes the Comfort Care DNR, EMS personnel shall resuscitate, since this raises an issue of doubt as to the validity of the form.

If there is any indication that the patient has revoked the Comfort Care DNR or if the EMS personnel have a good faith basis to doubtthe validity of the Comfort Care DNR, they are required to provide treatment to the fullest extent possible, subject to their level of training.