WHAT IS COMFORT CARE?
The program is an effort by the Massachusetts Department of Public Health, Office of Emergency Medical Services. The COMFORT CARE/DNR Order Verification Program, commonly known as Comfort Care, was developed for the benefit of patients who have made the decision with their physician(s) that they should be full DNR status and have a current DNR order.

WHAT WAS THE PROBLEM?
In the past it has been difficult, legally and practically, for EMS personnel to honor patient wishes in the community setting when treatment decisions have to be made in a matter of seconds. This program provides concrete verification that this person has DNR status and therefore gives clear guidelines as to how emergency medical personnel shall respond. So in cases where families panic and call EMS or if someone is in public or in a nursing facility where they may be required to call EMS, the patient will receive care in accordance with his/her wishes.

HOW IS CC/DNR VERIFIED?
By the presence of a numbered and signed form and an optional hospital-style bracelet. And by verifying that the identity of the patient corresponds to the holder of the DNR status. The form and bracelet can only be obtained through an MD, authorized PA or NP. This does not have to be the same person who signed the original DNR order. The patient should then wear the bracelet and keep the form with them. If they are bed-bound it should be posted on the door leading to their room or kept at their bedside. These are the places EMS personnel are trained to look. If EMS personnel can't easily find the bracelet or form they are legally required to initiate CPR. This applies even if a family member or health care proxy states the patient is DNR. People are also encouraged to notify their local ambulance service of participation in the program prior to any emergency.

WHAT KIND OF CARE WILL BE PROVIDED UPON VERIFICATION OF DNR STATUS?
Specifically EMS will not provide cardiac compression, endotracheal intubation, resuscitation medications, artificial ventilation, defibrillation, etc. If the patient is pulseless and apneic, EMS personnel will not transport to a hospital. So if someone had wished to die at home, the family would not have to go through following them to the hospital and dealing with all the staff and other inconveniences. But they will provide care to keep the person comfortable (hence the name of the program) including oxygen administration, pain relief, suctioning, positioning for comfort, initiating IV lines, application of cardiac monitor, and emotional support to the patient and family as indicated. It is a standardized, state-wide form and process. CC/DNR is an all or nothing program. So people who would want intubation and ventilatory support, but not resuscitation are not appropriate for the program. The employee must give seven days notice if the leave is foreseeable. If not foreseeable the employee must give as much notice as practicable.

WHERE IS THE CC/DNR APPLICABLE?
In any setting other than a hospital, so residents of nursing facilities for example for whom this program is appropriate should participate. Other examples would be assisted living, private homes, public areas, and during inter-facility transport.

DOES THE PATIENT HAVE TO BE COMPETENT TO SIGN?
Yes, but the form can be signed on the patient's behalf by a guardian or a health care proxy if the patient lacks capacity.

DOES THE FORM EXPIRE?
This is optional. An expiration date can be specified.

WILL EMS TREAT FOR OTHER PROBLEMS UNRELATED TO RESUSCITATION?
Yes.

HOW CAN A PATIENT REVOKE CC/DNR?
The patient may do this at any time regardless of mental or physical conditions, by the destruction or affirmative revocation of the CC/DNR Order Verification, or by direction that it not be followed or be destroyed. Patients shall be instructed, upon revocation, to destroy the CC/DNR Order Verification Form, the bracelet and the underlying DNR order. If someone identifies him/herself as the health care agent or guardian and revokes the CC/DNR in a resuscitation situation EMS personnel will resuscitate as this raises doubt on the validity of the CC/DNR. As such, patients are encouraged to discuss their wishes with family and significant others.

-Information for this article came from the Comfort Care Website: http://www.state.ma.us/dph/oems/comfort/ccare.htm And from Marianne Bitner, NREMT-P, Trinity EMS, Inc.

COMFORT CARE/DNR FOLLOW-UP QUESTIONS

In the last "MGH Community News" we invited readers to submit follow-up questions about the Comfort Care/DNR Order Verification Program. These questions, and the answers supplied by Marianne Bitner, NREMT-P, Clinical Director of Trinity EMS, Inc., are below.

When did the Comfort Care program go into effect?
It was introduced to MA physicians in the Spring of 1997 when an information packet with copies of the Comfort Care Forms was sent to all MA licensed physicians. All the EMS field providers were trained to look for the Comfort Care forms and bracelets during their recertification classes in 1997, but they could accept either the Comfort Care form or a physician written DNR until the end of December 1999. It became mandatory for all field EMS personnel to only accept the Comfort Care form/bracelet for field verification of a DNR on January 1, 2000.

Do we have information about what percentage of PCP's/MDs are knowledgeable about the Comfort Care program?
100% of MA licensed MD's have received letters and informational packets explaining the program and how to get the forms since the Spring of 1997, but we believe that probably only 50% of the MD's have knowledge of the program or have started to use the correct procedure and forms.

Are interns/residents educated about the existence of the Comfort Care program?
I (Marianne Bitner) spoke to the Tufts Family Practice Residents/Interns of Comfort Care this Spring, but I am not aware of any other formal presentations to interns/residents being done on Comfort Care. This needs to be done, but the State Office of EMS staff has not taken any steps that I am aware of to address this need.

How often/frequently has it been utilized thus far in the field?
Comfort Care forms are being used much more now then back before the mandatory implementation on January 1, 2000. Since January 1 different areas of the state and the EMS agencies in those areas have taken a proactive position to aggressively go out to do the education of MD's, nurses, nursing home staff, discharge planners, VNA's and social service personnel on who need Comfort Care forms/bracelets, where to get them and who can order them.

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