Letting Go: DNR Orders in Prehospital Care

We have come full circle in the 20 years since Pantridge and his associates moved the practice of cardiac resuscitation from the hospital into the community. Many victims of out-of-hospital sudden death have been saved in the intervening time, and those involved in prehospital care understandably have focused on preserving life by rapidly providing care at the scene of the patient's collapse. This emphasis saves lives, and resuscitation, at first applied almost exclusively to patients with ischemic heart disease, is now attempted for nearly everyone collapsing in public.

Giving paramedics guidelines for starting resuscitation is a problem. Many jurisdictions opt for legal safety by requiring resuscitation attempts in virtually all patients. Los Angeles paramedics are instructed to begin resuscitation in all cardiac arrest patients unless there is decapitation; massive crush injury or evisceration of heart, lung, or brain; incineration; rigor mortis; postmortem lividity; or decomposition. These criteria all address the