To the editor: In 2008, the Ontario Ministry of Health and Long-Term Care (MOHLTC) implemented a new Do Not Resuscitate (DNR) form for use by paramedics. ¹ This form is the only DNR documentation that Ontario paramedics are permitted to honour. At the time of its implementation, this form represented a significant step forward in that, for the first time in Ontario, paramedics were permitted to honour DNRs for prehospital emergency calls. Unfortunately, ambiguities remain, and the requirement for patients to have this one specific form means that people are often having their end-of-life wishes disregarded.

Uncertainty remains over what actions paramedics should be taking when encountering patients with this DNR form when cardiac or respiratory arrest has not yet occurred. For example, could a patient with a DNR who is unconscious but breathing spontaneously receive an oropharyngeal airway? The MOHLTC training package for paramedics defines cardiopulmonary resuscitation (CPR) as “an immediate application of life-saving measures to a person who has suffered a sudden respiratory or cardiorespiratory arrest” ¹ (emphasis added). This seems clear that it applies only to patients who have experienced a cardiac or respiratory arrest. Unfortunately, this directly conflicts with the interpretation given by some of the base hospital programs, at least one of which has explicitly advised paramedics that the DNR standard applies to patients even when they have not yet experienced a cardiac or respiratory arrest.Reference Lammers and Bradford ² This means that paramedics are being told to interpret Do Not Resuscitate as Do Not Treat, in some circumstances.

The even more important question is why paramedics are limited to this single DNR form and otherwise must disregard patients’ wishes. Currently in Ontario, if a patient’s spouse or other substitute decision maker tries to make a verbal informed refusal on their behalf when the patient is in cardiac arrest, paramedics cannot honour this. The reason that Section 20 (1) of the Health Care Consent Act ³ does not apply here has never been made clear.

Ontario is long overdue for the next iteration of DNR standards for paramedics. If one specific form is still to be used, it must be clarified so that all parties are clear on what having this form exactly means. Paramedics should also be given the latitude to respect patients’ wishes conveyed to them through means other than this one single form, particularly the verbal wishes of a substitute decision maker under the Health Care Consent Act.