Gen. 167] 167
HEALTH
E MERGENCY M EDICA L S ERVI CES

) L IFE -S USTAININ G P ROCED URES

) A UTHORITY FOR E MERGENCY M EDICAL S ERVIC ES P ALLI ATIVE C ARE /D O N OT R ESUSC ITATE P ROTO COL
January 30, 1995

Rober t R. Bass , MD, FACEP Maryland Inst itut

e for Emergency Medi ca l S

ervi ce s S ys te ms You have re quested our

opinion whethe r the M aryland I nstitute f or Emergency MedicalServ ices S ystems ( “MIEMSS”) has th e authori ty, in conjunc tion wit h the Board o f Phy sician Q uality Assurance (“BP QA ”), to issu e an “Em erge ncy Medical Ser vic es Pal liative Care/Do Not Res u scit ate Prot ocol” for pre-hospi tal providers.
For the reaso ns state d belo w, w e con clude that M IEM SS and the BP QA d o have this autho rity under curren t law.

I
Pr oposed M IE M SS Pr otocol
M IEM SS, with the BPQA’s concur rence, i s planni ng to is sue a protocolfor pre -hospit al prov iders to descr ibe the circums tances under wh ich em ergenc y me dical se rvices (“EM S”) pers onn el are to forgo effo rts at car diopulmonar y resusci tati on (“CPR”) that the y wo uld ordin arily ma ke. Th e new proto col w ill authori ze the use of pain reli ef

andother

com fo rt car e me as ur es , i nst ead

of CPR, if t

he patient’s atten din g p hysi cian has i ssued a pal liative care/ ”do not resusci tate ” (“DNR”) order on a f orm to be dev elopedand issue d by MIEM SS.
Under the pro pose d pro tocol, the patient’s atte nding phys ician wo uld is su e the pa ll iati ve ca re /DN R orde r only under cir cumstances authori zed by th e H ealth Care Decisi ons Act, Titl e 5, Subti tle 6 of168 [80 O p. Att’y

1 The protoc ol

woul d l i kewise ref l ec t both the gra nts of au th ori ty andthe l i m i tations el sew he re i n the Act. SeeH G §§5-60 1(n) (li mi ted de f i ni ti on of “ medi cal l y i ne f f ecti ve treatm en t”), 5-602 (h) (s tan

da rds f or he al th ca re age nts), 5-605(c) (standards for surrogat es), 5-606 (required cer t ifi cat ions by

phy sici ans), and 5-611 (m edi cally in eff ective lifesustai ni ng procedur

es). t he Health-Gener al (“ HG”) Articl e, Maryland Code. Thus, f or exa mple, the physi cian mi ght e nter t he order pur suant t o t h e patient’s instructi on in an adv ance dir ecti ve aft er the ap prop riate certi fication of the patient’s con dition had b een mad e. See HG §5- 606(b). 1
The ne w MI EMSS pr ot oc ol wo uld es ta blis h procedures to be foll owed by the attending physici an in compl eting the standard fo rm that MIEMSS will di stribute; t he crit eria f

or EM S perso nnel in determi ning whento in it ia te , wi th hol d, o r wi th dr aw CP R; and the types of care to be rende red in lieu of C PR.

II Outpati ent “Do NotResusci tate” Orders Under The Health Care Decis ion s Act
M IEM SS and th e BP QA have e xpli cit statutory autho rity to adopt a protocolthat wil l requi re EMS personnel to prov ide comfort care, instead of C PR, to a patient with an approp riate physician’s order. The Health Care Decis ion s Act in clude s an in struction to EM S perso nnel to follow a partic ular D NR proto col:

Certif ied emerge ncy medicalserv ices personnelshall be directe d by proto col to foll ow emerge ncy medicalserv ices “ do not resusc itate orders” pertain ing to adult p atients in the outpatient

sett ing i n accordance with proto cols establ ished by t he Maryland Institute fo r Emergency MedicalServ ices Syst ems in conju nct ion with the State Board of Physici an Qual i ty Assur ance. Emerg ency medical servic es “ do not resuscitate or ders” may not authorize the withholding of medi calGen. 167] 169

2 EMS personnel

who fol low a DNR

or der issued pur sua nt t o t his sect io n are im mun e from li abi li ty as a resul

t o f thei r withh oldi ng o r wi thdra wi ng CPR. HG

§5-60 9(a).

3 EMS pe rson ne l arealso t o fol

low a DNR order i ssued b y either an on-li ne EMS m

edi cal co mmand

and control phy

sici an or a phy

sici an ph ysic ally pres en t at the sc ene. HG § 5-608 (c)(2)(3 ). EMS pers on n el m ust, i n an y ev en t, provi de CP R to a pa ti en t wh o re quests i

t pri or to ca

rdi acor resp i ratory arres t. HG §5-6 08(b ).

4 We are aware of

nothin g in the le gi sl ative hist o ry t ha t wo uld

(conti nue d...) interv entions, or ther apies dee med ne ces sary to prov ide comfor

t care or to al lev iate pain. 2 §5-608(a) of the Heal th-General(“HG”) Art icle , Maryland Code. 3

An EM S DN R o rder is sp ecifically define d in HG §5-601 (h):

“Emerg ency medical servi ces ‘d o not resusc itate order’” mea ns a phy sician’s writt en orderin a form est ablis hed by protocol issued by the Maryland Inst i tute f or Em e rgencyM edica l Services [Sy stems] in conjunct ion with the State Board of Physici an Qual ity Assurance which , in the event of a cardia c or respirator

y arres t of a par

ticul ar pati ent, auth ori zes ce rti fie d eme rgenc y medical serv ices pe rso nnel to wit hhold or withdraw car diopulmonary resus citation including cardia c compressi on, endotr acheal i ntubati on, other ad va nc ed ai rwa y management

techni ques, artifi cial vent ilation, defibr ill ation, and other r elat ed lif e-sust aining procedures.
This definitio n limits th e s co pe of an EMS DNRorder t o “the eventof a ca rdiac o r respira tory ar rest ....” This term, n ot its el f define d in the act, is to be given its ordinary m eaning. See In r e Dougl as P. , 333 M d. 38 7, 39 2, 63 5 A.2 d 42 7 (19 94); Atkinson v
. State , 331 M d. 199, 2 15, 627 A.2d 10 19 (199 3). 4 In anear lier170 [80 O p. Att’y

4 (...co ntin

ued) c ause us to read t he term “cardia c or respiratory arrest” in any un co nve nt io na l wa y.

5 CPR invo lve s p r o ce du r es t ha t ar e “ ‘hig hly i ntrus i ve , and som

e are vio le nt in natu re . T he de fibrill at or , fo r e xample, cau ses vio lent ( and pa infu l) mus cl e contractions....’” In re Riddlemoser , 31 7 Md. 496 , 501 n.2, 564 A.2d 812 (1989) (quo ting Matter of Dinne rstei n , 380 N.E.2d 134, 13 6 (Ma ss. A

pp. 197 8)). opini on, we cite d the fol lowing de fini tions : “ ‘Cardiac arres t is the sudd en unexp ected cessation of heartbeat an d blood pressure.... Respiratory arrest i s the sudden cessa tio n of effective breathing.’” 79 Opinions of

the Attorney General

218, 221 (1994) (quo tin g Office of Te chn olo gy As sessment, Life- Sustai ning Technologi es and the E lderly 168 (19 85)). As a practical matter, t he s co pe of EMS DNR orders, as thus delim ited, might not alway s fully carry out the w ishes of a competent

patie nt or leg ally a

uthori zed decis ion-mak er on behalf of an incapaci tat ed pa tient . Suppose, for exampl e, that a pati ent in a termi nal conditi on had executed an advance di recti ve fl atly r uling out the us e of CPR. Such a directive presumabl y would refl ect the patient’s judgment

that the suf feri ng ass ociat ed with ev en success ful CPR was not justifi ed by a suff icie nt benefi t under t he circumstances. 5 A physician ’s order t o EMS personnel t o implement that advance di recti ve would l og ical ly rule out CPR even if t

he patie nt we re ex per ienc ing s erious cardiac or respir atory distr ess short of full arrest.
The Health C are Decisions Act, howeve r, does not addres s that conting ency. I f MI EMSS an d the BPQA h ave aut horit y to is sue a protocolcall ing f

or palli ativ e care, instead of CPR, in circums tances other t han cardia c or resp iratory a rrest, the sourc e of tha t autho rity lies elsewhere than in the Ac t.
III

Au thority to Issu e P allia tive Ca re P rotocol Among other r esponsibi lit ies, t he E MS Bo ard at M IEM SS is to “dev elop and adopt

a Emergency MedicalSyst em plan to ensu re effe ctive c oo rdinat ion and ev aluat ion of emer gency medi cal ser vic esGen. 167] 171

6 EMS per so nnel who follow t he pa lli at ivecar e as pec t s o f such a protoc ol would do so wi

thi n th e i m m un i ty granted by

§§5-309, 5-309.1, and5-310 of the Courts and Judici al Proceedings

Articl e, Mary la nd Code. deliv ered in thi s St ate.” § 1 3-1D-09(a) of the Educati on (“ED”) Arti cle, Maryland Code. The plan i s to i nclude “ [c]r iteria and guide lines for the deli very of emerge ncy medicalserv ices i ncluding provi sions to assur e propermedical direction of emerg ency medical services.” ED §13-1D -09(b)(1)(ii).
I n accordance wit

h this plan “ and other r elev ant pol icie s adoptedby the E MS B oard,” the Executi ve Direc torof M IEM SS is to “[c]oordinat e a st at ewide syst em of Emerge ncy Medical Serv ices ,” “[c] oordinat e the traini ng of al l pers onnel in t he EmergencyMedical Ser vic es Syst em and devel op the nec ess ary standar ds for their ce r tifica tion ,” a nd “[ i]mplem ent all p rogr ammatic , operational, and administ rativ e components o f th e Institute.” ED §1 3-1D -10(1), (4), and (12).
Taken as a whol e, thes e pr ovisio ns a uth oriz e the Ex ecu tive Director of MIEMSS, worki ng withi n the fra me wo r k of t he EMS pl an, to establish protoco ls under w hich EM S personne l are to b e trai ned, certi fied, and gov erned in t heir day- to-day oper ations . I f the Executiv e Direct or beli eves t hat the policie s und erlying th e H ealth Care De cisions Act ca n bes t be fu rth ered by a prot ocol that addresse s not only DNR order s for pa tient s who suffer cardia c or respirator

y arrest but als o DN R orde rs for pat ients who are not yet clinically in cardi ac or resp iratory a rrest, the Executi ve Direc tor may develo p suc h a pr otoco l. 6
Further more, the Board of Phys ician Quality A ssurance has statutory authori ty to par ticipate i n the adopt ion of such a pro tocol. Under §14-305 of the Health Occupat ions (“HO”) Art icle , Maryland Code, a n emergenc y medica l technician-param edic may perform withoutlice nsure cer

tain a ctiv iti es that

fall with in the scope of the practi ce of medici ne. Speci fical ly, HO §14 -305(d) provi des as follows: Subject to t

he rules, regul ations, and orders of the Board, an emerg ency medicaltechni cian-paramedic, wh ile deliv eringemerge ncy healt h c ar e serv ices or undergoi ng trai ning, may perfor m the foll owing ser

vic es with out a lic ense :172 [80 O p. Att’y (1) All phases o f cardiopulm onary resusc itation; (2) All phases of pr ehospit al a dvance d life sup port; (3) Adm iniste ring of dru gs or intra venous solut ion as direct ed by a li cense physi cian by radio, tele metry, or written or or al ins truct ion; and (4) Obtaini ng blood forlab orator y analysis.
See also HO §14-303 (b) (cardiac res cue technicians). The “rul es, regulatio n s, and ord ers of the B oard” ma y include the BPQ A’s c oncurr ence in a pa lliative care p rotoco l for certa in patie nts receiving the services of these pre-ho spital providers.

IV
Con clusion
In s ummary, it

is our opinion that

MIEMSS and the Board of Physici an Quality A ssuranc e have a utho rity to issu e a pro tocol to implement DNR and palliati ve care orders by physicians.
J. Joseph C urran, Jr. AttorneyGeneral
Jack Sch wa rtz Chief Counsel Opinions & Advic e