I appreciated the article by Veena Guru and colleagues on the response of paramedics to terminally ill patients experiencing cardiac arrest.1 However, I am not convinced that the development of an out-of-hospital do-not-resuscitate (DNR) protocol for paramedics is the most effective way to address these challenging situations. Rather, provincial legislation regarding health care directives can provide a uniform approach for all health care providers and the general public.
In 1992 Manitoba adopted the Health Care Directives Act, which outlines the process of producing an advance health care directive and defines the protection from liability that exists if treatment is withheld while acting "in good faith in accordance with the wishes expressed in a directive."2 Such legislation obviates the need for separate policies for paramedics, nursing staff and others who must deal with a cardiopulmonary arrest in a patient for whom an advance directive outlining DNR wishes exists.
In Manitoba we also do not require a physician to pronounce death in a patient who has died at home when death was the expected outcome of an advanced terminal illness. A physician involved in caring for the patient must notify the chief medical examiner and the funeral home in writing about an anticipated death at home. When death occurs, the patient is taken to the funeral home and the physician can sign the death certificate in the office or hospital.
Together with an advance health care directive outlining a DNR request, this prenotification step effectively addresses the dilemma of resuscitation of the terminally ill patient at home, as long as supporting legislation exists. These very difficult circumstances need not be made more so by adherence to resuscitation policies in clearly inappropriate circumstances, against the wishes of patients and families.