No, Idaho is not under a ‘universal DNR.’ Hospitals won’t just let everyone die.
A misleading claim about Idaho’s hospital crisis has gone viral
A claim that everyone in Idaho is now under a “do-not-resuscitate” order — that they won’t be revived if their heart stops in the hospital — has gone viral on social media. But it’s not true.
The state entered “crisis standards of care” last week, giving Idaho hospitals, nurses and doctors an ethical framework to help them make decisions about using scarce resources during the COVID-19 surge.
Dr. Frank Johnson, St. Luke’s Health System chief medical officer, worries that it might keep people from going to the hospital.
Johnson chairs the St. Luke’s crisis standards committee.
“We don’t want people who are in need of emergent care to stay away from the hospital. If you’re having chest pain (or) symptoms of a heart attack or stroke, my goodness, come to the hospital,” he said.
St. Luke’s Health System on Saturday addressed the claim on its own social media accounts.
“To be clear, there is no ‘universal DNR’ at St. Luke’s,” the health system said on Twitter. “The state of Idaho includes a reference to ‘universal DNR’ in their Crisis Standards of Care Activation plan. The state’s plan contemplates and provides guidance on a range of issues that provider organizations may or may not have a need to implement. St. Luke’s does not include this element in our Crisis Standards of Care plan and our internal CSC steering committee has recommended against having such a policy. We understand area providers are taking a similar approach.”
As with most misinformation, there is a grain of truth
The Idaho crisis standards of care plan includes in its guidance a section about what to do if, for example, there’s a ventilator shortage. One part of that guidance addresses whether to try reviving adults whose hearts have stopped, even if they’re not already on a ventilator.
Adult patients hospitalized during a public health emergency, when crisis standards of care have been declared (and a hospital is using the mechanical ventilation allocation framework due to demand for ventilators exceeding supply), should receive aggressive interventions; however, they should receive NO attempts at resuscitation (compressions, shocks or intubation if not yet intubated) in the event of cardiac arrest. The likelihood of survival after a cardiac arrest is extremely low for adult patients. As well, resuscitation poses significant risk to healthcare workers due to aerosolization of body fluids and uses large quantities of scarce resources such as staff time, personal protective equipment, and lifesaving medications, with minimal opportunity for benefit. This universal DNR order does not apply to pediatric patients; however, pediatric patients requiring a ventilator after resuscitation would enter the ventilator triage protocol after resuscitation, just like other patients needing ventilator access.
– Patient Care Strategies for Scarce Resource Situations guide for Idaho crisis standards of care
So in theory, it is possible that a person who goes into cardiac arrest could be allowed to die. But first, three things must happen:
- Crisis standards of care must be declared. That happened statewide on Thursday.
- Hospitals operating under crisis standards would have to include this “universal DNR” in their own plans. St. Luke’s, which is Idaho’s largest hospital system, does not currently have a universal DNR in its plan to deal with the COVID-19 crisis.
- And this is the “important part,” says Johnson: A hospital must not have enough ventilators. The shortage must be significant enough for a hospital to be forced into using the “mechanical ventilation allocation framework.” Johnson said that applies to “nobody I know in the state” at this point. St. Luke’s still has enough ventilators, he said. Earlier this week, it was using 77 of 101 in its supply and recently placed orders for 20 more to arrive in the next couple of weeks, he said. “We’re limited in staff, for sure, we’re limited in space, for sure, but ventilators, we still have enough,” he said.
It’s also important to note that the state plan is a framework. It is meant to help hospitals make an impossible choice: decide who gets life-saving care when they don’t have enough for everyone. It is not an order for hospitals or medical workers to withhold medical care when they can adequately provide it.
Johnson notes that the Idaho crisis standards plan doesn’t apply to just this crisis. It is a framework developed for any overwhelming medical crisis — whether that’s a pandemic, a natural disaster or a sudden mass casualty event.
St. Luke’s and other hospitals are digging out older ventilators and requesting more to meet the demand from a growing number of COVID-19 patients. But they’re not at a point where they need to stop doing CPR on patients, Johnson said. He says a “universal DNR” is more likely in an immediate crisis scenario.
“You’ve got Hurricane Katrina, all the power’s out, the hospitals are flooded. … You have 30 people who need a ventilator in the ICU, and you only have 20 (ventilators),” he said.
Idaho is in crisis standards, which is very serious. And it was preventable; almost all hospitalized COVID-19 patients are unvaccinated.
Crisis standards could mean some people won’t get life-saving care. It could mean that health care providers will have to decide which patient is most likely to be saved by one ventilator. But, at least for now, it doesn’t mean every adult is marked “DNR.”
Johnson provided the Sun with a document St. Luke’s prepared Friday. It addresses DNRs and other questions about how St. Luke’s is managing crisis standards.