State of State of DelawareDelaware

Pre-Hospital Advanced Pre-Hospital Advanced Care Directive Regulations Care Directive Regulations

(PACD)(PACD)

What is PACD?What is PACD?

A Pre-Hospital Advanced Care Directive A Pre-Hospital Advanced Care Directive (PACD) allows (PACD) allows terminally ill patientsterminally ill patients, , upon discussion with their primary upon discussion with their primary physician, the right to elect to either physician, the right to elect to either receive full, limited, or no resuscitative receive full, limited, or no resuscitative efforts by EMS field responders.efforts by EMS field responders.

Living Wills

Power of

Power of AttorneyAttorney

““DNR”DNR”

““DNI”DNI”

Prescription padPrescription pad

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Why Do We Need It?

Goals of the RegulationGoals of the Regulation

To eliminate the confusionTo eliminate the confusion To mandate a specific form for the To mandate a specific form for the

pre-hospital environmentpre-hospital environment Establish guidelines for different Establish guidelines for different

levels of carelevels of care Detail the immunity for providers Detail the immunity for providers

honoring the requesthonoring the request

How Long Have We Had It?How Long Have We Had It?

Introduced November 1, Introduced November 1, 20022002

Public comment period – Public comment period – November 26November 26thth through through December 31December 31stst

Effective Date – July 10, Effective Date – July 10, 20032003

Specific FormSpecific Form

Delaware Health and Social Services Delaware Health and Social Services Division of Public HealthDivision of Public Health

Pre-Hospital Advanced Care Pre-Hospital Advanced Care Directive (PACD) For Terminal Directive (PACD) For Terminal

Illness OnlyIllness Only

Scope of Emergency Medical Services Scope of Emergency Medical Services CareCare

What Does It Look Like?What Does It Look Like?

What Are Our What Are Our Responsibilities?Responsibilities?

Primary Care PhysiciansPrimary Care Physicians– Explaining the form to their terminally ill patientsExplaining the form to their terminally ill patients– Explaining the options of pre-hospital careExplaining the options of pre-hospital care– Helping the patient select the option they desire Helping the patient select the option they desire – Helping the patient fill out both the form and Helping the patient fill out both the form and

wallet cardwallet card– Keeping a copy of the PACD form in the patient’s Keeping a copy of the PACD form in the patient’s

medical records.medical records. EMS Field RespondersEMS Field Responders

– Locating the signed PACD form Locating the signed PACD form – Determining its validityDetermining its validity– Adhering to the option of care chosenAdhering to the option of care chosen

Three OptionsThree Options

The patient may The patient may choose from three choose from three levels of carelevels of care

Each level defines Each level defines specific treatment specific treatment optionsoptions

Option AOption AAdvanced Life Support Advanced Life Support

Maximal (Restorative) Care Before Maximal (Restorative) Care Before Arrest, Then DNRArrest, Then DNR

If pulse present, full scope of If pulse present, full scope of restorative interventions permissible restorative interventions permissible under the Delaware Statewide ALS under the Delaware Statewide ALS treatment protocols treatment protocols

Upon cardiac arrest all efforts shall Upon cardiac arrest all efforts shall cease.cease.

Option BOption B

Basic Life Support Basic Life Support

Limited (Palliative) Care Only Limited (Palliative) Care Only Before Arrest, Then DNRBefore Arrest, Then DNR

If pulse present, EMS will provide “comfort If pulse present, EMS will provide “comfort care” for control of signs and symptoms care” for control of signs and symptoms

Upon cardiac arrest no further care.Upon cardiac arrest no further care.

Palliative CarePalliative CareEMS EMS WILLWILL provide: provide:

Opening AirwayOpening Airway

– Jaw thrustJaw thrust

– Head-tilt chin liftHead-tilt chin lift

– Finger sweepFinger sweep

– OPA / NPAOPA / NPA

OxygenOxygen

SuctioningSuctioning

Control of bleedingControl of bleeding

Fracture Fracture

immobilizationimmobilization

PositioningPositioning

Pain meds may be Pain meds may be

administered only by administered only by

family or family or anotheranother HCP HCP

Palliative CarePalliative CareEMS EMS WILL WILL NOTNOT Perform Perform

PacingPacing

CardioversionCardioversion

DefibrillationDefibrillation Initiation of IV therapyInitiation of IV therapy

EMS Meds (except OEMS Meds (except O2 2 ))

CPRCPR

PASGPASG

IntubationIntubation

– ETTETT

– Combi-tubeCombi-tube

– LMALMA

Gastric TubeGastric Tube Active ventilatory Active ventilatory

assistance unless assistance unless on a ventilatoron a ventilator

Option COption C

Do Not Resuscitate (DNR) Do Not Resuscitate (DNR)

No Care Administered of Any No Care Administered of Any KindKind

No care of any kind will be given by No care of any kind will be given by EMS unless the patient wishes to EMS unless the patient wishes to

revoke the PACDrevoke the PACD

““I’ve changed my mind”I’ve changed my mind”

The patient and only the patient may The patient and only the patient may revoke this at anytime by providing some revoke this at anytime by providing some sort of communication to the care providers.sort of communication to the care providers.

- Verbally- Verbally- Eye Blinking- Eye Blinking- Finger Tapping- Finger Tapping- Any other form of Any other form of communication to communication to indicate a desire to indicate a desire to revoke the PACDrevoke the PACD

The PACD FormThe PACD Form

Must be signed and dated by the patient Must be signed and dated by the patient and the primary care physician.and the primary care physician.

The patient and physician name, address The patient and physician name, address and phone number must be printed.and phone number must be printed.

Must denote the Option of Care selectedMust denote the Option of Care selected

If the form is incomplete it is If the form is incomplete it is invalid.invalid.

Record-KeepingRecord-Keeping Original document is kept w/patient’s Original document is kept w/patient’s

permanent medical records/files at the permanent medical records/files at the facility providing primary carefacility providing primary care– Physician’s office Physician’s office – Hospital Hospital – Nursing Home Nursing Home – Other health care provider facility.Other health care provider facility.

A copy is kept w/patient A copy is kept w/patient – at the patient’s home, orat the patient’s home, or– at the health care facility where patient is at the health care facility where patient is

admitted and receiving medical care/treatment admitted and receiving medical care/treatment

Wallet CardWallet Card

The purpose of the wallet card is to alert The purpose of the wallet card is to alert emergency field personnel to the fact that emergency field personnel to the fact that a signed PACD form exists a signed PACD form exists

EMS Providers MAY NOT honor the wallet EMS Providers MAY NOT honor the wallet card alonecard alone

We MUST have the signed PACD form in We MUST have the signed PACD form in order to honor the PACDorder to honor the PACD

DocumentationDocumentation

We will document that we saw the form We will document that we saw the form and desired option in the EDIN reportand desired option in the EDIN report

We will document that the form found at We will document that the form found at the scene was turned over to the hospital the scene was turned over to the hospital for inclusion in the patient’s record, orfor inclusion in the patient’s record, or

That the form was retained by the EMS That the form was retained by the EMS agency for their recordsagency for their records– DOPA or other non-transportsDOPA or other non-transports

If the patient revokes the PACD, the If the patient revokes the PACD, the revocation and how it was communicated revocation and how it was communicated will be documentedwill be documented

LiabilityLiability

EMS is included in the immunity EMS is included in the immunity provisions of the State’s Health-Care provisions of the State’s Health-Care Decision regulations as a result of Decision regulations as a result of withholding or withdrawing any withholding or withdrawing any health care.health care.

Common QuestionsCommon Questions

Q - Q - What if the nursing home only What if the nursing home only has has their DNR paperwork?their DNR paperwork?

A – A – We can only recognize the state We can only recognize the state approved approved PACD form. We will PACD form. We will contact medical control for guidance if contact medical control for guidance if presented with another form of DNR presented with another form of DNR orderorder

Common QuestionsCommon Questions

Q – Q – What if the form is not completed?What if the form is not completed?

A – We can only honor the form if it is complete. Otherwise, we will provide full EMS care and contact medical control for further guidance.

Q – Q – What if the patient is injured and What if the patient is injured and not not dying from their terminal illness?dying from their terminal illness?

Common QuestionsCommon Questions

A – If the terminally ill patient is injured, the PACD will be followed in accordance with the option selected.

Q – Q – What happens with an Out of What happens with an Out of State State DNR?DNR?

Common QuestionsCommon Questions

A – Standardized EMS DNR orders from another state approved by the Director of the Division of Public

Health shall be honored and treated as Option B (Palliative Care Only).

QuestionsQuestions