To Ask, or Not to Ask?

Over on Hybrid Medic's blog, he has a post about a call where he hadn't noticed the patient had a DNR.  I started to comment on it, and that comment kept growing, and turned itself into a whole post, so I brought it over here.  Go read his post first.

I recently had a non-EMS friend tell a story about her mother going to an ER, and getting really freaked out by the nurse asking if she had a DNR. The patient, and the family, interpreted it to mean that the nurse thought she was about to die. This brought up a good discussion of why the nurse would ask, and what might have been a better way to do that.

With a nursing home transfer, where they give you all the paperwork, the DNR will either be there or not, so it's fairly simple most of the time.  But for other calls... when do you ask?  How do you decide?  Age of the patient?  Condition?  History?  And how do you ask?

My friend's story was interesting timing, coming within a couple of days of a call where the patient was talking to us as we walked in, I saw the DNR on the counter, and the patient promptly collapsed and died.  So it was a very good thing that we had seen the DNR without even having to ask.

Since my friend's conversation about her awful experience, I've been pretty careful about asking. I've had some patients who, for reasons basically a combination of age and condition, I've considered what all might happen throughout the call and on into any hospital stay, and felt like I should ask.  I've tried to preface it as a routine question, which it sort of is, and sort of isn't, and let the family know that the question itself doesn't mean I think something terrible is about to happen, but that we just need to know so we know what the patient wants.

I'm not entirely satisfied with what I've come up with so far.  Better than blurting it out, yes.  But not optimal yet.

We had another call, for a very sick patient, where I didn't think to ask, primarily because I was busy with my assessment, and the family, midway through things, asked me "Did you see the DNR on the refrigerator?"  Um.  No.  I didn't.  I don't think I saw the refrigerator, actually.  But I was glad they brought it up.  Didn't change what I did, but it could have.

Maybe part of what we need to do is educate people with DNRs, and their family members, to always make sure we know about it?

We've also had a call where the family said the patient had a DNR, but they didn't have it there, it was at someone else's house, or something like that.  Someone went to find it, while we continued resuscitation efforts.  Brought up questions of how to educate people that if they have a DNR, if that is really what they want,  they need to have it WITH THEM.  There is no way to predict when something might happen that they'll need it, and if they need it, they need it right then.  Not later.

Most people in this culture don't even want to think about it, let alone discuss it. Educating people can be very difficult, if they don't want to even hear about it at all, let alone consider how it might apply to them.

I think that was the cause of the uncomfortable interaction with my friend and her mother, and the nurse.  From the nurse's point of view, she asked because it would make it easier to know what the patient wanted, and provide that. Whether she was about to die right then, or not, dying is something people eventually do, and part of the nurses' job is dealing with that, so talking about it was no big deal at all.  From the family's perspective, TALKING about dying was a big deal, all on its own, so for someone to even ASK was a big deal.

How can we bridge that gap?