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DNR Orders, Advanced Directives, and Death Determination

Category: Operations Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-04

Overview

EMT-Basics regularly encounter patients with advance directives that limit or prohibit resuscitative efforts. Understanding the legal and ethical framework in New Mexico is essential — acting without appropriate authority (initiating resuscitation against a valid DNR) or failing to act when required (not resuscitating a patient without a valid directive) both carry serious consequences.

This article covers: criteria for withholding resuscitation based on obvious signs of biological death, and honoring valid advance directives/DNR orders.

Part 1: Determination of Death / Withholding Resuscitation

When to Withhold Resuscitation

Resuscitation must be started on all apneic and pulseless patients UNLESS one of the following conditions exists (does not apply to lightning strikes, drowning, or hypothermia — these require full resuscitation attempts):

Signs of irreversible biological death: - Decapitation: complete severing of the head from the body - Decomposition/putrefaction: skin bloated or ruptured; soft tissue sloughed; these signs indicate death at least 24 hours prior - Transection of the torso: body completely cut across below shoulders and above hips - Incineration: >90% BSA full thickness burns with ash instead of clothing and complete absence of body hair with charred skin - Dependent lividity with rigor mortis: clear demarcation of pooled blood under skin when clothing removed, AND body is generally rigid - Injuries incompatible with life: massive crush injury, complete exsanguination, severe displacement of brain matter

OR

Valid DNR order or other actionable medical order (MOST form, DNR card/bracelet) — see Part 2.

Key Points

  • If ANY of the above signs are confirmed → CPR is not required
  • If CPR has already been initiated and the above signs are subsequently confirmed → CPR may be discontinued; contact Medical Control
  • Lightning strike, drowning, and hypothermia are exceptions — full resuscitation attempts required regardless of apparent state

Part 2: DNR and Advanced Directives

Types of Advance Directives in New Mexico

  1. Physician Orders for Medical Orders for Life Sustaining Treatment (MOST) — explicitly describes acceptable interventions; must be signed by a physician or other empowered medical provider; is in the form of actual medical orders

  2. Do Not Resuscitate (DNR) order — identifies that CPR and intubation are NOT to be initiated if patient is in arrest or peri-arrest; must be a valid, current order

  3. Advanced directives — document describing acceptable treatments in various clinical situations including cardiac arrest, artificial nutrition, organ donation, dialysis; note: frequently does NOT apply to emergent or potentially transient medical conditions

  4. Durable Power of Attorney (DPOA) for Healthcare — in the absence of formal written directions, a DPOA holder or healthcare proxy may prescribe limits of treatment

Validating an Advance Directive

A DNR or advance directive is valid when it meets ALL of the following: - Conforms to state specifications for color and construction - Is intact: has not been cut, broken, or shows signs of being repaired - Displays the patient's name and the physician's name

If there is question about validity: proceed with resuscitation and obtain additional information to clarify; do not withhold care based on a questionable document.

If there is any indication of attempted homicide: initiate resuscitation until questions are answered; contact Medical Control.

What EMTs May Do for a DNR Patient

Even with a valid DNR, EMS may provide comfort-oriented care: - Administer oxygen by mask or cannula - Suction - Manage airway (except intubation and advanced airway maneuvers) - Control bleeding - Make patient comfortable - Comfort family

Resuscitative measures to withhold for covered patients in cardiac/respiratory arrest: - External chest compressions - Artificial ventilations, intubation, or other advanced airway maneuvers - Defibrillation/external cardiac pacing - Administration of cardiac medications - Artificial respiration

DNR + Signs of Life

If there is a DNR but the patient has signs of life (pulse AND respirations) → provide standard appropriate treatment per existing protocols matching the patient's condition. The DNR applies to cardiac/respiratory arrest, not to a living patient with acute illness.

Do Not Intubate (DNI) Only

If there is a DNI directive (not a full DNR), the patient receives full treatment per protocols with the exception of the specifically prohibited intervention (intubation). If a prohibited intervention is being considered, contact Medical Control.

Multiple Documents

Where a patient has both a DNR order and a Durable Power of Attorney, the most recent document prevails for prehospital treatment only.

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

Key EMT-B actions with DNR/MOST: - Verify identification: driver's license, family member, or third-party identification - Verify the document: intact, patient name, physician name, state-compliant format - If valid: withhold specified resuscitative measures; provide allowed comfort care - If CPR already initiated and valid DNR subsequently verified: may discontinue; contact Medical Control - If any question of validity: proceed with resuscitation; contact Medical Control - Document all actions, document discussions, document document-verification process

Termination of resuscitation criteria (from Medical Cardiac Arrest and specific rhythm protocols): - Consider termination after 40 minutes of resuscitation efforts without ROSC (40 minutes from time of last shock or from beginning if no shock ever indicated) - ETCO2 <10 mmHg or falling >25% despite resuscitation indicates poor prognosis and supports termination - Contact Medical Control for transport or termination of resuscitation instructions

NREMT Relevance

  • Signs of irreversible death that allow withholding resuscitation: decapitation, decomposition, torso transection, incineration, dependent lividity with rigor mortis, injuries incompatible with life
  • Exceptions: lightning, drowning, hypothermia — always attempt resuscitation
  • Valid DNR: intact, patient name, physician name, state-compliant color/construction
  • DNR patient with signs of life → treat for current condition (DNR only covers cardiac/respiratory arrest)
  • DNI patient → full treatment except intubation
  • Comfort care always allowed: O2, suction, bleeding control, comfort measures

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Determination of Death/Withholding Resuscitative Efforts (p. 80); DNR/Advanced Directives (p. 81–82)