Prenotification in cases of death at home
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* P. Richard Verbeek
* Laurie J. Morrison

**[Two of the authors respond:]** 

We appreciate and support the perspective offered by Mike Harlos. In addition to paramedics, others who may encounter this situation are firefighters and, in the near future, lay responders who are trained in public-access defibrillation. "Good faith" liability protection that is broad in scope would better serve societal needs and permit a more uniform response to out-of-hospital expected deaths. The Manitoba solution may serve as a template for change in Ontario.

All out-of-hospital programs of which we are aware rely on the availability of a written DNR request, yet we found that 70% of DNR requests were verbally expressed. A recent survey of our basic life support paramedics suggests that only 44% were comfortable with a verbal DNR order.1 Therefore, the success of such programs requires that physicians consistently engage patients and their caregivers in discussions about end-of-life issues, including advanced directives.

To complement the link between the treating physician and coroner's office, there should also be a link that is unique to emergency medical services (EMS). The responding paramedic should not have the responsibility of deciding the veracity of a DNR request if the EMS system is inadvertently activated. Instead, the patient's directive should be registered with the EMS system so that paramedics can receive notification of a verified DNR request prior to arriving at the patient's residence.

Society has determined that the autonomous individual (or the individual's advocate) has the sole right to make decisions regarding personal care. Ultimately, the out-of-hospital needs of the patient at the time of death should dictate the design of the system. Unfortunately, in Ontario, the converse is true today.

## Reference

1.  1. Sherbino J, Guru V, Verbeek PR, Morrison LJ. Defining the paramedics' ethical dilemma with DNR orders in the prehospital setting [abstract]. CJEM 1999;1(3):171.