Medical Direction

Medical Direction Q & A

This “Medical Direction Q & A” is provided for informational purposes only. Individual agencies should consult their medical director and legal counsel when drafting their own individualized protocols, trainings, and quality assurance processes.

Although a medical director can restrict elements of the Ohio scope of practice, the medical director shall never exceed the scope regardless of the training provided or protocols available.

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Scope of Practice

Can a paramedic transport a patient who has an arterial line or intraarterial catheter in place? Can the paramedic transport the patient with this device in place if the transferring facility caps off or heplocks the device prior to transport?

The insertion, maintenance, monitoring, or utilization of arterial lines lies outside of the Ohio EMS scope of practice for all levels of Ohio EMS certification even if the device is capped or locked. As such, a mobile intensive care unit (MoICU), which requires a registered nurse within its staffing matrix, would be required for the transport of patients with these devices in place. From a clinical standpoint, patients who are ill enough to require arterial access and/or monitoring, such as arterial lines or aortic balloon pumps, should be transported by a MoICU in the interest of patient safety.

The only exception is if a patient with established arterial access dispatches EMS from home or a non-medical facility via 911 or if a healthcare facility requires emergent evacuation due to a declared emergency. In these scenarios, the arterial access device is classified as pre-existing, and all Ohio EMS providers can transport the patient emergently to the appropriate facility to avoid the potential delays inherent with waiting for a higher level of care. This is outlined in the position paper approved by the State Board of Emergency Medical, Fire, and Transportation Services (EMFTS Board) regarding transport of patients with pre-existing devices or drug administrations. While this scenario was never encountered in the out-of-hospital settings in the past, there have been advancements in medical technology where patients, albeit rare, are maintained at home with arterially placed or accessed devices. An example of this type of device that can be maintained in the outpatient setting is the surgically-inserted hepatic arterial infusion pumps that are utilized to administer chemotherapy and other medications.

If the advanced EMT is authorized to administer intravenous narcotics and benzodiazepines, why is the administration of ondansetron (Zofran®) limited to oral route for the advanced emergency medical technician (AEMT) while the Paramedic is permitted to administer this medication intravenously?

Prior to becoming available to the medical community or to the general public, all new medications must undergo rigorous testing for efficacy and patient safety to acquire approval from the Food and Drug Administration (FDA). While the testing required by the FDA may involve a small population of human subjects, there are times when adverse effects are not revealed until after the drug has been approved and is being administered to the larger patient population. A prime example is the case of gatifloxacin (Tequin®), an antibiotic that was deemed safe by the FDA and, at the time of its release, was marketed as the best antibiotic for the treatment of upper respiratory infections. When it was noted that people, including young healthy college students with bronchitis, were dying of fulminant liver failure while taking Tequin®, the FDA removed it from the market and the drug has now been banned worldwide.

When unanticipated adverse effects are noted following a drug's approval and release, the FDA can elect to issue an informational warning for minor side effects, issue a "black box" warning for potentially life-threatening side effects, or remove the drug from the market for irreconcilable breaches of the threshold of patient safety. In the case of Zofran®, the FDA issued a black box warning in September 2011 due to a noted significant trend in the incidence of QT prolongation, with several cases resulting in patient death, following the administration of this drug intravenously. QT prolongation is a serious cardiac side effect which can be the precursor to life-threatening arrhythmias as well as complete heart block. Although less severe than a black box warning, the FDA issued a cautionary warning in September 2016 regarding Zofran® administration to pregnant patients due to a possibility of increased birth defects, particularly cleft palate. However with this cautionary warning, the FDA deemed that additional research is required to confirm the link between Zofran® and adverse effects to the fetus.

The Ohio EMS scope of practice allows cardiac monitor strip interpretation at the AEMT level of certification. However, the administration of the medications required to adequately treat QT prolongation are not within the AEMT scope of practice. As such, the intravenous administration of Zofran® is only permitted at the Paramedic level of certification.

Of note, the Ohio EMS scope of practice has age and weight limitations for the administration of oral Zofran® by AEMTs to the pediatric patient population. The FDA has noted a higher incidence of cardiac side effects which includes, but is not limited to, torsades de pointes in younger children. While the AEMT may recognize these arrhythmias on a cardiac monitor strip, the administration of the medications required to treat this side effect is limited to the Paramedic level of certification. Following the recommendation of the EMS for Children (EMS-C) Committee, the State Board of Emergency Medical, Fire, and Transportation Services (EMFTS Board) approved these parameters for the administration of oral Zofran® by Ohio AEMTs.

Benzodiazepines and narcotics, such as fentanyl or morphine, have serious side effects. The most frequent potentially life-threatening adverse effect is respiratory depression which can be treated with adequate airway management and, if indicated, naloxone. Airway management and naloxone administration are within the AEMT scope of practice which has facilitated the EMFTS Board's decision to approve narcotic and benzodiazepine administration by AEMTs with the requirement of EMS medical director approval and a written protocol.

While the EMFTS Board fully acknowledges the challenges of communities that have few or no Paramedics, the exclusion of intravenous Zofran® administration by AEMTs and the established boundaries for the administration of oral Zofran® to pediatric patients should not be interpreted by EMS agencies as an act to deprive patients of care. The top priority of the EMFTS Board is the patient. Patient care and safety are paramount, and they are the EMFTS Board's primary goals when determining the Ohio EMS scope of practice. It would also be irresponsible of the EMFTS Board to place patients, EMS agencies, and EMS providers at unwarranted medicolegal risk by approving the administration of a medication under less than optimal conditions following the issuance of a national black box warning by the FDA.

Paramedics are permitted to “maintain blood administration,” but what exactly is permissible from the State’s perspective?

  1. It is often appropriate to treat shock earlier with blood products rather than with crystalloid fluids. If the referring site has already INITIATED the transfusion of a unit of PRBCs, does “maintenance” include the Paramedic administering an additional (i.e., second) unit while on transport? For example, if the referring site has two units of PRBCs to administer, the transporting squad is there quickly, and the referring nurse has already verified that both units are O negative, it would seem to be in the patient’s best interest to “continue” with the administration of the second unit of PRBCs while enroute, once the first unit’s transfusion is complete. Does “maintaining” mean one specific unit of PRBCs, or does maintaining refer to the overall process of blood administration, as already physician ordered?
  2. Related to this, does “blood administration” mean PRBCs, or is it permissive to include other blood products? Again, one is often administering FFP along with the blood. So, is “blood” a somewhat generic term, and can FFP or platelets also be administered if the process of blood product administration has been initiated at the referring site?

The maintenance of a blood transfusion DOES NOT INCLUDE INITIATION even if it is subsequent units provided to an EMS provider regardless of who has checked the blood. If a patient is anticipated to require additional blood products beyond what is hanging at the time EMS presents for transport, the transferring physician should use a mobile intensive care unit (ground or air), rather than an ALS unit, as a registered nurse is required in the MoICU staffing matrix. Also, if a patient is sick enough to require the transfusion of additional blood products beyond what has been initiated, it is in the best interest of the patient to be transferred by the appropriate level of care which would be a mobile intensive care unit.

When an EMS unit accepts a patient for transport where maintenance of a blood transfusion is required and/or requested, they must be provided with orders from the transferring physician and/or the EMS medical director on how it should be administered, i.e. infusion rate. Physician orders must be provided to EMS for any infusing medication, including blood products.

The maintenance of a blood transfusion is inclusive of any blood product. It can be packed red blood cells, whole blood, FFP, platelets, etc. All of these blood products fall under the category of “blood”.

What is required (training, medical director approval, continuing education, quality assurance, written protocol, etc.) for EMS providers to transport patients with heparin drips? What about other types of IV drips such as Dobutamine, Norepinephrine, Potassium, Cardizen, Tridil, etc.?

The provision of all emergency medical services, including the administration of any medication, requires approval of the EMS medical director, a written protocol, training (far in advance of performing any skill or administering any medication), continuing education, and a quality assurance program or process. The maintenance of an IV and fluid administration is within the Ohio EMS scope of practice for the Advanced EMT (AEMT) and the Paramedic. This is cited in Ohio Revised Code 4765.38 (B)(1).

For AEMTs, the only medications that they are permitted to administer are those medications that have been approved by the Emergency Medical, Fire, and Transportation Services (EMFTS) Board. The medications that have been currently approved for administration by AEMTs are cited in Ohio Administrative Code 4765-16-01 (B)(1)(e).

For Paramedics, Ohio Revised Code 4765.39(B)(5) permits them to administer appropriate drugs and intravenous fluids. At this level of EMS certification, the EMFTS Board has not generated a list of medications that are specifically prohibited. As stated previously, all medication administrations and emergency medical services provided require approval, a written protocol, training, continuing education, and a quality assurance process provided by the medical director. For additional guidance, the EMFTS Board has also provided a position paper on interfacility transport of patients by EMS providers and the scope of practice.

In all cases, it is our shared goal to provide the best service to the patient and to maximize patient safety. To achieve this goal, there are medications that are appropriate for EMS providers to administer. Likewise, there are medications that are more appropriate for administration by a registered nurse during transport with a mobile intensive care unit. The best practices are achieved when the patient’s healthcare and safety needs are the primary guiding light paired with educated decisions and common sense from the medical director.

Regarding the maximum dose of naloxone via mucosal atomization device by EMRs and Basic EMTs: My understanding is the maximum dosage is 2 mg total. However, our protocol states that more can be given if a positive change in the patient is noted. Please explain.

While the standard dose that is most often seen in the medical literature is 2 mg, this is certainly not the dose that is written in stone nor is it the maximum dose. For the treatment of a patient with altered mental status, 2 mg is a dose that is commonly used by EMS medical directors for the initial dose to administer to an adult, but varied doses may be warranted in certain patients.

Unless there is a change in the dose, strength, or type of opiate taken, chronic opiate abusers may respond to smaller doses of naloxone than a person whose body has not developed a tolerance to the opiate. This is one of the reasons why the opiate withdrawal symptoms after naloxone administration may be more prominent in a chronic opiate abuser.

Having said that, we live in a different world today than we did 10 years ago. The abuse of stronger opiates require much larger, and possibly multiple subsequent, doses of naloxone to reverse the respiratory depression associated with an opioid overdose. Fentanyl, which is 100 times more potent than morphine, is being sold on the streets or mixed with heroin. Even chronic opiate abusers may require much more than 2 mg of naloxone to reverse the effects of an overdose if fentanyl is involved.

So, the answer to your question is that if a patient with a confirmed or suspected opioid overdose does not respond to 2 mg of naloxone, it is perfectly acceptable to administer more naloxone.

A healthcare facility that frequently initiates care for acutely ill patients that exceed their medical capabilities and resources contacts EMS to transfer these patients to a facility with a higher level of care. These requests for transport may involve patients with acute STEMIs, patients with PICC lines, or patients with nitroglycerin infusing via an IV pump. Assuming that an ALS unit is unavailable and the transferring physician feels that patient cannot wait for one to become available, would it be appropriate for a BLS unit to perform the interfacility transport of this patient with the nitroglycerin infusing on an IV pump if the EMTs do not change, adjust, or stop the IV pump?

Although these patients are often very ill, a Paramedic, at a minimum, would be required for the transport of a patient with infusing medication. Anything less would be a breach of the Ohio EMS scope of practice and also not in the best interest of the patient’s safety. The State of Board of Emergency Medical, Fire, and Transportation Services (EMFTS Board) permits a BLS unit to transport a patient with a PICC line; however, an infusion of any substance during transport is not permitted.

The only other scenarios where the EMFTS Board supports a variance in the Ohio EMS scope of practice is in the prehospital setting (e.g. EMS runs initiated by 9-1-1) and emergent interfacility (i.e. disaster, mass casualty incident, healthcare facility evacuation in a declared disaster) transfer of patients with pre- existing medical devices. For example, if a BLS unit was dispatched to a residence where a patient had a PICC line in place as part of their outpatient treatment plan, the patient could be transported emergently to a healthcare facility without waiting for an AEMT or a Paramedic to arrive. This does not include the routine/scheduled interfacility transfers of patients to acute care facilities (e.g. hospitals or emergency departments) nor does it include the transfer of patients out of an emergency department or hospital due to events such as emergency department overcrowding or physician convenience/impatience. The EMFTS Board’s stance on this can be found in their position paper on EMS provider transport of patients with pre-existing medical devices of drug administrations.

For the scenario that is described in the question where a patient is being transferred from a healthcare facility to a facility for specialized care or treatment, this is considered an interfacility transport to an acute care facility. The position paper on pre-existing medical devices does not apply in this case. Even if the patient is direly ill, the EMS provider must maintain compliance with the Ohio EMS scope of practice for the respective level of Ohio EMS certification. In addition, the transferring physician, per federal EMTALA regulations, has a responsibility to transfer the patient via an appropriate level of care. For this scenario, an ALS unit is the minimum acceptable level of care that should accompany this patient. An additional option would be to transport the patient via a ground or air mobile intensive care unit which requires a registered nurse in the medical team’s staffing matrix.

It is imperative for all EMS providers to be compliant with the authorized Ohio EMS scope of practice for their respective level of EMS certification. Failure of compliance or failure to decline patient transports that require skills that lie outside of the Ohio EMS scope of practice can result in fines, suspensions, revocation, or permanent revocation of one’s Ohio EMS certificate to practice.

If a patient with respiratory problems and has an Ohio DNR Comfort Care (DNR-CC) document, is the administration of bronchodilators permitted or does this constitute the resuscitation that they do not wish to receive? Is there anything in the Ohio EMS scope of practice to address these issues?

The Ohio DNR Comfort Care program was created by and is housed in the Ohio Department of Health. While the program provides the only transportable form of advance directive for EMS that provides immunity, the Ohio DNR-CC document and the associated patient care parameters apply to all healthcare institutions and professionals including EMS providers. As such, the program’s patient care parameters are not addressed in the Ohio EMS scope of practice.

Patients who are enrolled in the Ohio DNR Comfort Care do not wish to have a cardiac monitor applied. It is important to note that, for the Ohio DNR Comfort Care program, the definition of a cardiac arrest is the loss or lack of a palpable pulse. Unlike conventional ACLS protocols, this definition of cardiac arrest does not include or require the interpretation of the rhythm on a cardiac monitor. In addition, the definition of a respiratory arrest for the Ohio DNR Comfort Care program is agonal respirations or apnea.

For patients who are enrolled in the Ohio DNR Comfort Care program, the healthcare provider will perform the following actions:

  • Suction the airway
  • Administer oxygen
  • Position for comfort
  • Splint or immobilize
  • Control bleeding
  • Provide pain medication
  • Provide emotional support
  • Contact other appropriate health care providers such as hospice, home health, attending physician/clinical nurse specialist (CNS)/certified nurse practitioner (CNP)

For patients who are enrolled in the Ohio DNR Comfort Care program, the healthcare providers will not perform the following actions:

  • Administer chest compressions
  • Insert artificial airway
  • Administer resuscitative drugs
  • Defibrillate or cardiovert
  • Provide respiratory assistance (other than listed above)
  • Initiate resuscitative IV fluids
  • Initiate cardiac monitoring

“Do not resuscitate” is not equivalent to “do not treat”. The administration of bronchodilators to patients who have enrolled in the Ohio DNR Comfort Care program is permitted. Bronchodilators are not classified as resuscitative medications. They can be self-administered by the patient or administered passively via a nebulizer, non-rebreathing face mask, or via a non-invasive positive airway pressure device (BiPAP/CPAP). They cannot be administered via a device where the healthcare provider is actively providing respiratory assistance (e.g. bag valve mask, endotracheal tube). The administration of IV fluids for rehydration or medication administration is permitted, but they should not be given for the purpose of resuscitation from a cardiac and/or pulmonary arrest. If a patient has pneumonia or other infectious process, the administration of antibiotics is permitted unless declined by the patient. The medications that should not be administered to patients enrolled in the Ohio DNR Comfort Care are those that are used to treat ventricular fibrillation, pulseless ventricular fibrillation, pulseless electrical activity (PEA), or asystole as well as vasopressors.

For patients who are enrolled in the Ohio DNR Comfort Care-Arrest (DNR CCA) program, they wish to receive unrestricted medical care until they do not have a palpable pulse, develop agonal respirations, or become apneic. At that time, any cardiac monitoring equipment and/or invasive airway devices should be removed, and the Ohio DNR Comfort Care parameters immediately become effective in this patient population.

Patients who are enrolled in the Ohio DNR Comfort Care program can terminate their document verbally or in writing at any time; however spouses, family members, or friends cannot amend or nullify it without the patient’s permission. As in all patient scenarios, the patient always retains the right to refuse any medical intervention, treatment modality, or medication even if its provision is permitted within the parameters of the Ohio DNR Comfort Care program.

Our local EMS system is considering the inclusion of septic shock as a time-critical diagnosis where patients at risk who are identified in the field will be preferentially transferred to a facility that can provide a higher level of care. Is the performance of point-of-care testing for lactate and other measurements, such as hemoglobin, by our paramedics permitted? Are there any limitations for the performance of point-of-care testing for Ohio EMS providers providing services within a mobile integrated healthcare system?

The performance of point-of-care testing is within the Ohio EMS scope of practice for the paramedic as long as the body fluid that is analyzed is blood. Ohio Administrative Code 4765-17-03(A)(21) authorizes blood chemistry analysis by the paramedic, and the regulation does not limit the substance or chemical parameters assessed (4765-17-03). Although certified Ohio paramedics may perform blood chemistry analysis, the performance of point-of-care testing by emergency medical technicians (EMTs) and advanced emergency medical technicians (AEMTs) within the Ohio EMS scope of practice is only permitted for the use of glucose monitoring systems.

The Ohio EMS scope of practice that has been authorized by the State Board of Emergency Medical, Fire, and Transportation Services (EMFTS Board) is identical for both emergency and non-emergency situations. Therefore, the authorized services cited within the Ohio EMS scope of practice, including point-of-care testing, can be performed during patient care delivery within a mobile integrated healthcare system. As with all actions within the Ohio EMS scope of practice, authorization and a written protocol from the EMS medical director is required.

Is transporting a patient with nutrition infusing through a PEG (percutaneous endoscopic gastrostomy) tube within the Ohio EMS scope of practice?

A PEG tube is a pre-existing medical device. Some patients are prescribed intermittent administration of nutrition through a PEG tube by their physician while others require continuous administration. Although it is more of a concern with intravenous hyperalimentation, the abrupt disruption of continuous nutrition may result in patient harm due to the onset of rapid hypoglycemia or other conditions dependent upon the patient's medical history and other medications being provided.

The management of patients with indwelling medical devices (e.g. PEG tubes, nerve stimulators), invasive medical devices (e.g. Foley catheters, subcutaneous insulin pumps), or mechanical devices (e.g. ventilators, left ventricular assist devices (LVADs)) in the outpatient setting is increasing in frequency. The State Board of Emergency Medical, Fire, and Transportation Services (EMFTS Board) has issued and approved a position paper regarding the transport of patients with pre-existing medical devices or drug administrations. For emergent patient transports, i.e. 911 dispatch or emergent interfacility transfers due to declared disaster or emergency, all EMS providers can transport patients with pre-existing medical devices including PEG tubes with nutrition infusing.

For routine interfacility transports, the transferring physician must assure that the transporting service and the scope of practice of its personnel are aligned with the patient’s needs and are adequate for the maintenance of patient safety. Regardless of the wishes of the transferring physician, the EMS provider may never exceed the Ohio EMS scope of practice or provide services that have not been authorized by the EMS medical director or included in the EMS medical director’s written protocol. The EMFTS Board has issued and approved a position paper regarding interfacility transport of patients and the scope of practice to assist EMS medical directors in the decision-making process regarding various medical services that are not specifically addressed in Ohio Revised Code 4765 or Ohio Administrative Code 4765.

While EMS providers should not initiate tube feedings, a PEG tube with infusing nutrition is essentially a medication administered via a pre-existing medical device. For interfacility transports, the rate of continuous PEG tube feedings is typically written in the physician’s orders and the tube feeding is controlled by an IV pump. A paramedic is the only level of Ohio EMS certification authorized by the EMFTS Board to use an IV infusion pump. As such, a paramedic is required for the interfacility transport of patients with an IV infusion pump regardless of the medications or substances provided through the IV pump or the route or device through which they are administered. The rate of infusion of the tube feeding is can be provided by the EMS medical director or is often previously ordered by the transferring physician.

Patient Transport

EMS has been dispatched to a facility that provides long-term healthcare and short-term rehabilitation services. The staff at the facility is requesting a patient be transported to the hospital for evaluation, but the patient refuses transport. What is the responsibility of the Ohio EMS providers when staff at a healthcare facility insist a patient be transported, but the patient refuses?

The civil right of a competent adult to refuse medical treatment is established in federal law, specifically 42 CFR 483.10 of the Code of Federal Regulations. This civil right is not amended or voided based upon the residence or location of the patient. As such, it remains in effect even when a patient is a resident of a long-term or short-term healthcare facility. The competent adult can refuse treatment at any time before or during the course of a medical evaluation, treatment or transport to a medical facility. Violation of this civil right may result in criminal charges that include, but are not limited to, kidnapping, battery or assault.

The civil right of a competent adult to refuse medical evaluation, treatment, or transport to a medical facility cannot be amended or voided by a patient’s advance directives (e.g., living wills, do not resuscitate (DNR) documents or orders, Ohio Comfort Care) or a document stating that the patient had requested full or selected measures. In addition, a family member or power of attorney for healthcare cannot supersede a patient’s refusal of transport or treatment while the patient is clinically competent.

The only scenario where a competent patient can be transported to a healthcare facility against his or her will is if they meet one or more of the criteria cited in Ohio Revised Code 5122.01 (B). This is the law that allows patients who are suicidal, homicidal, exhibiting psychotic behavior, or those that may benefit from a psychiatric evaluation to be transported to a healthcare facility and held for up to 72 hours.

An adult who is clinically incompetent or unconscious is within the category of patients who have, due to their clinical condition, provided implied consent for medical treatment. These patients may undergo a medical evaluation, treatment and transport to a medical facility without obtaining formal consent and their inability to do so should not be considered equivalent to a refusal. In these cases, the civil right provided by 42 CFR 483.10 to refuse medical treatment becomes delegated to the person’s legal guardian or power of attorney for healthcare. For EMS providers, the delineation and confirmation of a legal guardian or power of attorney for healthcare can be difficult, if not impossible, to determine in the field. For these scenarios, the EMS medical director along with the EMS agency’s legal counsel should determine the protocol for which EMS providers should follow. An advance directive document may be a helpful guidance; however, the Ohio DNR Comfort Care program is currently the only form of advance directive that provides civil immunity to EMS providers who are compliant with the patient’s documented wishes.

EMS was dispatched and arrives on scene to find a patient who has an animal. The patient requests that the animal accompany them to the hospital. What actions are required to be taken for service animals versus emotional support animals?

The American Disabilities Act, 42 U.S. Code § 12101, chapter 126, is a federal statute that defines a service animal and cites the requirements that must be met for them. A service animal is defined as an animal that is individually trained to do work or perform tasks for people with disabilities. Under the current federal regulation, only dogs or miniature horses can serve as service animals. By law, the animal is required to be under control, i.e. leashed, harnessed, or tethered, unless these devices interfere with the service animal's work or the individual's disability prevents using these devices. If the latter is the case, the animal's behavior must be able to be controlled by verbal commands, signals, or other methods or devices. State and local governments, businesses, and nonprofit organizations that serve the public generally must allow service animals to accompany people with disabilities in all areas of the facility where the public is normally allowed to go.

Within the realm of EMS, the transport vehicle is not a location where the public is normally allowed to enter independently. In addition, patient care must always remain the top priority for EMS providers. For patients with service animals, every attempt should be made to transport the animal with the patient just as one would try to maintain the possession a communication assistance device or a probing/white cane with patient who has a disability related to sensory deficits. In emergent life-threatening scenarios, patient care and transport should never be delayed. If, for some reason, the service animal is not able to board the ambulance in a timely manner or the physical presence of the animal would interfere with the EMS provider's ability to provide emergently needed services, e.g., cardiopulmonary resuscitation, the service animal should be reunited with the patient as soon as possible upon arrival at the receiving healthcare facility.

Emotional support, therapy, or comfort animals are not service animals. They are not trained to perform a specific task, and they typically provide benefit to the patient simply by their physical presence. The American Disabilities Act does not provide any protection for emotional support animals. As such, EMS providers are not required to transport emotional support animals with the patient, maintain their accompaniment with the patient, or ensure that the animal has alternative transport for reunification with the patient at the receiving healthcare facility.

DNR & Death Determination/Pronouncement

What should I do if I respond to a patient who is DNR and the relatives or nursing home staff on scene want us to resuscitate the patient? Also, what happens if a patient in cardiac arrest is going through a divorce and his/her spouse informs us that the patient has a living will and does not want to be resuscitated?

Advance directives are available in a variety of formats. Traditional living wills can be generated by an attorney or by a physician. Durable power of attorney for healthcare documents allow a patient to designate his or her medical decision-making to another party in the event that the patient becomes mentally or physically incapacitated or incompetent. Living wills and power of attorney for healthcare documents can be generated by an attorney at the direction of a client who may be a patient or the patient’s legal guardian or can originate as a court order. In the past, durable power of attorney for healthcare documents were usually generated by attorneys; however, this resource is now available on the internet for individuals, as well as physicians, to complete and execute independent of legal counsel.

Traditional do-not-resuscitate orders may exist as a verbal physician order or as a written physician order documented in a patient’s hospital or extended care facility medical record. This may include a physician order to exclude specific resuscitative and/or nutritional measures in addition to an order not to resuscitate a patient in the event of a cardiac arrest. The legal authority of these orders are usually limited to the healthcare facility in which they are written and, in some institutions, must be renewed at the time of readmission to a facility. While the paradigms of physician orders for life-sustaining treatment (POLST) and medical orders for life-sustaining treatment (MOLST) have been initiated in other states; however, POLST and MOLST programs have not currently been legislated or implemented in Ohio.

At this time, there are two legislative citations from the State of Ohio regarding advance directives, including do not resuscitate (DNR) orders, that have the greatest impact upon Ohio EMS providers. The Ohio DNR Comfort Care program, which includes the Ohio DNR Comfort Care and the Ohio DNR Comfort Care-Arrest protocols, is housed in the Ohio Department of Health. It is the only form of advance directive that provides civil immunity to Ohio EMS providers. It is also the only form of DNR order that is transportable with the patient during transitions between various facilities. Once completed, the only parties authorized to void the Ohio DNR Comfort Care document is the patient (or the patient’s power of attorney for healthcare if this individual was the signatory on the document at the time of enrollment in the program) or two physicians who agree that the document should be temporarily or permanently voided. The Ohio DNR Comfort Care form and the patient care parameters associated with the program can be found HERE.

While the presentation of the Ohio DNR Comfort Care document to EMS providers is preferable, the Ohio Department of Health has designed a DNR Comfort Care logo that is printed on all of their materials. As soon as Ohio EMS providers see the DNR Comfort Care logo on or accompanying a patient, they may initiate the patient care parameters outlined in the program immediately and retain civil immunity. Wallet cards and wristbands bearing this logo are readily available and can be more conveniently carried by a patient enrolled in this program (click HERE to see Ohio Department of Health DNR resources). The legislation and regulation regarding the Ohio Department of Health’s DNR Comfort Care program are cited in the Ohio Revised Code 2133.21 through 2133.26 and in the Ohio Administrative Code 3701-62. Additional resources provided by the Ohio Department of Health are available HERE.

The second legislative citation that may impact Ohio EMS providers in the course of patient treatment where resuscitation issues may be involved is Substitute House Bill 451 which prevents certain persons from making life support decisions. This bill was signed by Governor Kasich on January 4, 2017, and the law became effective on April 6, 2017. This new law “provides that an individual's statutory priority to decide whether or not to withhold or withdraw life-sustaining treatment for the individual's relative is forfeited if the individual is the subject of a temporary protection order or civil protection order and the relative is the alleged victim or if the individual and the relative are married and the parties to a divorce, dissolution, legal separation, or annulment proceeding, to void any objections to a living will made by a person whose statutory priority would be so forfeited, provides that an attorney in fact under a durable power of attorney for health care is competent to make decisions pertaining to life-sustaining treatment, nutrition, or hydration, only if the attorney in fact is not subject to a temporary protection order or civil protection order in which the principal is the alleged victim.”

For the Ohio EMS provider and other emergency care providers, it may be difficult or impossible to definitively determine the existence or status of a temporary protection order or civil protection order or the legal familial or marital status between a patient and another person. Likewise, it may be impossible to determine the validity or active status of the other previously mentioned advance directive documents (living wills, DNR orders that are not Ohio DNR Comfort Care, power of attorney for healthcare, etc.) while on scene.

From a medicolegal standpoint, the Ohio DNR Comfort Care program is the only form of advance directive that provides immunity to the Ohio EMS provider as long as the comfort care parameters are followed. For all other cases, it is advisable to initiate resuscitation if a person’s DNR status is unknown or cannot be quickly determined or confirmed and to contact medical direction. For the patient care and decision-making process for those not enrolled in the Ohio Department of Health’s Ohio DNR Comfort Care program, the EMS medical director ultimately has the authority on how these patient scenarios should be managed. The EMS agencies and EMS providers should follow the protocols provided to them by their EMS medical director.

EMS providers are dispatched for an unresponsive person and upon arrival find the patient in rigor mortis. Can the EMS providers pronounce the patient dead?

Pronouncement of death is not permitted to be performed by Ohio EMS providers regardless of their level of certification. Certified EMTs, AEMTs, and paramedics are classified, by Ohio Administrative Code 4731-14, as competent observers. Competent observers are authorized to determine death. EMRs are not authorized to determine or pronounce death.

The termination of resuscitation is not analogous or equivalent to the pronouncement of death. They are two distinctly separate and independent events and actions. EMS providers may terminate resuscitation with authorization and a written protocol from the EMS medical director. The pronouncement of death must be completed by a physician or, with the cited parameters satisfied, by the specific medical professionals listed in Ohio Administrative Code 4731-14-01.

With regards to the guidance provided to serve as a competent observer, it is entirely up to the EMS medical director to include the parameters to be used in the protocol to determine death such as rigor mortis or decapitation. The skills needed to determine obvious death do not typically exceed the Ohio EMS scope of practice for the EMT, AEMT, or paramedic.

Waveform Capnography

On January 1, 2021, waveform capnography will become required for all patients who require invasive airway devices. Will waveform capnography be required if an EMS provider places a supraglottic airway device to manage a patient’s airway?

An invasive airway device is any device is inserted or pre-positioned into the patient’s airway via the mouth, directly into the trachea (tracheostomy tube or cricothyrotomy), or via nasotracheal intubation. Therefore, supraglottic (dual lumen or extraglottic) airways devices, even though they are blindly inserted into the hypopharynx or the esophagus, are invasive airway devices and will require waveform capnography effective January 1, 2021. Waveform capnography is an important patient care adjunct as it facilitates the assessment of adequate patient ventilation and, in the scenario of cardiopulmonary arrest, is useful in the detection of return of spontaneous circulation. Waveform capnography is also critical for the early detection of displacement or malfunction of the airway device as well as obstruction of the patient’s airway or the lumen of the airway device.

Non-invasive airway devices will not require utilization of waveform capnography on January 1, 2021. Non-invasive airway devices include nasal cannulas, face masks, and non-invasive positive airway pressure devices (continuous (CPAP) or bi-level (BiPAP)). Although it is not mandatory, the utilization of quantitative waveform capnography, such as with nasal cannulas where the sampling port is manufactured as part of the device, or digital capnometry is recommended. A pulse oximeter can only measure the patient’s oxygen saturation. The measurement of capnography or capnometry is a more accurate assessment of the patient’s ventilatory status. This measurement may also be the first indication that a patient is developing respiratory failure due to fatigue, hypoventilation and/or excessive carbon dioxide retention, or airway obstruction from airway swelling, secretions, or foreign bodies.

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