title: Prehospital emergency medical services.
abstract: OBJECTIVE
  Our primary objectives were to estimate how frequently emergency medical technicians with defibrillation skills (EMT-Ds) are forced to deal with prehospital do-not-resuscitate (DNR) orders, to assess their comfort in doing so, and to describe the prehospital care provided to patients with DNR orders in a system without a prehospital DNR policy (i.e., where resuscitation is mandatory).
  
  
  METHODS
  Using Dillman methodology, the authors developed a 13-item survey and mailed it to 382 of 764 EMT-Ds in the metropolitan Toronto area. Responses were evaluated using 5-point Likert scales, limited-option and open-ended questions. Narrative responses were categorized. Two authors independently categorized narrative responses from 20 surveys, and kappa values for agreement beyond chance were determined.
  
  
  RESULTS
  Among 382 EMT-Ds surveyed, 236 (62%) responded, of whom 221 (94%) answered the questionnaire. Overall, 126 of 219 (58%) indicated that they were called to resuscitate patients with DNR orders "sometimes," "frequently," or "all the time." In such situations, 22 of 207 (11%) stated they would honour the DNR order and 55 of 207 (27%) would honour the order but appear to provide basic resuscitation, in order to adhere to mandatory resuscitation regulations. Willingness to honour a DNR order did not vary by years of emergency medical service. EMT-Ds cited concern for the family and the patient, fear of repercussions and conflict with personal ethics as key factors contributing to this ethical dilemma. If legally allowed to honour DNR orders, 212 of 221 (96%) respondents would be comfortable with a written order and 137 of 220 (62%) with a verbal order.
  
  
  CONCLUSIONS
  Prehospital DNR orders are common, and a significant number of EMT-Ds disregard current regulations by honouring them. EMT-Ds would be more comfortable with written than verbal DNR orders. An ethical prehospital DNR policy should be developed and applied.
authors.affiliation: Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Sherbino
authors.forename: V
authors.initials: V
authors.lastname: Guru
authors.forename: P R
authors.initials: PR
authors.lastname: Verbeek
authors.forename: L J
authors.initials: LJ
authors.lastname: Morrison