Hospice Code

[trauma1534]

Hello everyone... I ran into a very unusual thing last week at work. We were dispatched out to a 59 yof, possibly not breathing. When we got there, was an EMT already on the scene, working a code. When I walked in, I found a lady laying in a hospital type bed, with CPR in progress. The EMT reported to us that she had only been down about a min before his arrival, and she is a hospice patient with no valid DNR... and family was begging him to do something. They had just became a Hospice patient, and all the paper work was not final yet. Well... I checked patient for a pulse, breathing, all that stuff. Nothing. My partner was hooking up the AED. I took compressions while all this was happening. The EMT on scene started just bagging with good ventilation... very good rise and fall of cx. We hit analize... it said check patient... when I check for a corotid, there it was... just bounding. Good... now we have a pulse... time to secure an airway... nothing but agonal resps at this time. So I tubed her... perfect tube. Now... assisting her breathing with her own resps picking up to 12 a min, still unresponsive. We have a good HR at 100, good resps at 12 with assistance and intubated. All of a sudden, the one who wanted us to work her, steps up and now wants us to stop working her. We have a patient back. Now, they want to let her go!!! GRRRR!!!! So I explained to the family member that we now have her back. We are getting ready to transport. The Family memeber is now begging me to stop working her. She has POA. So... my partner called med control. The Dr. gave us the order to stop everything... pull the tube and put her on a NRB, and keep her on the monitor, and wait for Hospice to arrive or her to expire which ever comes first, if that is the family's wishes. So... I explained again the the family that she was back... good heart rate... good increasing resps...they still wanted to stop it all. So... I pulled the tube... put her on 15 lpm NRB, and let her be. She lasted exactly an hour. This was a hard call for me to deal with. While she was terminal, if there is no valid DNR, the EMT responder did the right thing by working her. We got her back and then had to pull her airway and let her die. When hospice arrived, right before she took her last breath, the nurse told us that we did the right thing. She stated that the moment that CPR was initiated, the patient was no longer a hospice patient. We had no choice but to work it. What would you have done and why?

 

[Epi-do]

Since there was not a valid DNR, we would have worked her - we wouldn't have had a chance to do anything else. Although we may have called medical control once the POA wanted things stopped, I am certain that we would not have been allowed to stop, especially since you had the patient back. We would have been required to transport to the ER, and if the family tried to stop us, PD would most likely have been contacted to assist us.

It sounds like even if the patient had been transported, the end result was going to be the same. I think you did everything right. You called medical control and were granted orders to stop. It was a tough run, all the way around and you did the best you could. Good job!

 

[Flight-LP]

Having dealt with several similar situations, I can attest that they are never easy.

First and foremost, families should NEVER state the word hospice unless appropriate documentation is present at the pts. bedside clearly indicating hospice or pallative care. Along with that needs to be clear legal documentation identifying the MEDICAL POA, not just a regular power of attorney. If all of the needed documentation is present, check to see if the pt. has signed it. If the patient indicates on hospice paperwork that he does not want to be resuscitated, then your answer is pretty simple.

Outside of having nothing and a family that obviously has an inability to cope with their decisions, yea I would have worked them too. BUT.....................

It will be a cold day in hell before I ever pull my own ET tube on an attempted resuscitation regardless of family wishes. At that point I could care less what their thoughts or wishes are, nor do I care about any documentation that may materialize. Pt. goes to hospital intubated, the inability of family to have their affairs in order will be dealt with later. All it takes is one family member to change their mind and only one word will be uttered...........MURDER!

Now granted you did what you were told by some Doc, that may work in your system, but we do not have on line medical control, we are strictly an autonomous off line system. Plus they wouldn't back us anyways, too many EMS systems and too many stupid EMTs and Paramedics. There is little trust in most EMS services.

Sorry you had a rough one, my thoughts are with you, hope your week gets better!

Flight

 

[Ridryder911]

I agree with Flight.. I too have been in some similar controversial settings.
Personally, without the written DNR, she would had been worked. Family or no family.

In this situation, I would had placed into them into the truck before we started any ALS and major resuscitation efforts. Once inside the truck all bets are off, I would advise the physician of the situation on the way in. They can cease resuscitation efforts.. and pronounce if they want to code to stop.. I do not allow families to yo-yo... if they don't like it .... tough, it is far better to err on the patients behalf.

R/r 911

 

[Rattletrap]

Also remember that the rules for hospice have changed, a pt may be in hospice and not have a DNR. I have been seeing this more and more with the different hospice programs I deal with.

 

[RedZone]

I was in a similar situation myself about 2 years ago. The patient's wife called 911 when the patient stopped breathing. We arrived to the scene, and I quickly discovered that the patient had a terminal illness. I asked the wife if there was a DNR, and she couldn't immediately find it, but her "daughter who is a nurse" is on the way over.

We had no choice but to start CPR. When the daughter arrived, she presented us with a living will. As per NYS DOH, the only advanced directive we may accept at a private residence is a Nonhospital Order Not to Resuscitate on an official NYS DOH form. We explained to the family that after a few minutes, we would attempt to convince med control to pronounce. As Murphy's Law would have it, the patient was successfully resuscitated rather easily, and we transported to the hospital.

The ED attending at the hospital was quite familiar with EMS policy, and understood our dilemma. But when our medical control physician found out, he made an unnecessary comment that was overheard by my partner's fiancee. My partner brought it to our director's attention and a good ole fashioned "sit-down" was demanded.

Our medical control physician researched the laws and invited a few ED nurses to our conference. All was settled, and we were found to have acted appropriately. He even admitted that if we did not attempt resuscitation, we could have been held legally responsible for the death of the patient.

Laws with advanced directives vary from state to state, region to region. My experience is, most providers are misinformed about advance directive rules!! Nurses, fellow EMTs and medics, doctors..... ask any 10 providers to explain advanced directive policy and you will get 15 very different answers.

Follow what your laws are, and if you have a concern, call medical control. But keep in mind some general rules (although they may vary by your local regulations):

- Regardless of whatever paperwork your patient has, if the family requests resuscitative efforts.... the DNR is no longer valid.

- If a patient is in hospice, he or she has accepted death is imminent. Their cardiac arrest was not of sudden onset. You didn't "let the patient die"!! The patient died because of his/her terminal illness. Resusciation is usually futile as the patient may have a severely decreased quality of life.

- While nobody has a right to kill themself, people DO have a right to die. You must separate your personal beliefs and accept that others share different beliefs.

- Discussing calls that bother you with more experienced people is a good thing. I hope the advice you received here helps.

- I do not agree with Flight LP here with one thing. While my system would have never let us "pull the tube", if your medical control doctor does advise you to do this as per family decision... it is not murder. Failing to follow this decision would be FELONY ASSAULT AND BATTERY.

 

[Airwaygoddess]

Very good replys and sound steps in getting all of the correct infomation for the patient and for the EMS providers.

 

[trauma1534]

- I do not agree with Flight LP here with one thing. While my system would have never let us "pull the tube", if your medical control doctor does advise you to do this as per family decision... it is not murder. Failing to follow this decision would be FELONY ASSAULT AND BATTERY.[/QUOTE]

Very good thought there! It's a hard pill to swallow! In 13.5 years of my career, this has to be the toughest call ever for me. Thank you all for your comments on this one. Everything has been helpfull! It's a hard thing to except that a patient was brought backl by my hands and then she also died by my hands! My shift alone has been slammed very hard recently... I know for the last 2 months! I'm just wondering when it's going to calm down for a bit! I've had a code each shift, 3 saves, 2 died after the save, I've had to fly out two patients, one motorcycle fatality last weekend, and this. Every patient I've picked up in the two months has been either circleing the drane or already down it! I know I'm in this business for that... however... sometimes a provider needs a few stomped toe calls to keep thier sanity! We see way too much sometimes in this business. One of my codes was a 17 year old trauma code from an MVC. Just when does it stop? Believe it or not, we got her back... she did die later on the OR table, but not on us! It's just touch sometimes. Thank you all for being there!

As for our med control, they are very open to our treatments. We have protocols, but all meds are standing orders. They trust us too much sometimes. If we want to call a code in the field, they are usually ok with it... whatever we want to give... they trust us. We have to be good. It opens us up for a law suit for them to be so open.

 

[RedZone]

The only thing I can offer is, stop thinking that they died by your hands. Would you have felt better if the patient had lived as a vegetable? They died because they had already been dying from whatever terminal illness. As you even stated, not all post-arrests actually walk out of the hospital.

I really am not sure why your medical control doc asked you to pull the tube.... but he/she did, and maybe that's acceptable in your system. I'd consider discussing this call with the doc, but if that would cause you to feel worse, then maybe you're better off 'moving on'. That's up to you.

Hopefully you won't run into this same situation again, but if you do, you can try explaining to the family that you will transport to the hospital, and the doctors, nurses, social workers, and other staff will consider their wishes and help decide what's best for the patient... even the possibility of ceasing extraordiary lifesaving measures if appropriate.

And yes, I do agree with you that after calls like these, I begin to appreciate the drunks and the stable patients a little more! Hopefully the next few calls will cheer you up soon!

 

[Tincanfireman]

These calls are tragic all the way around, but you had Med Control direction to pull the tube, so in my mind you are covered legally. It sounds like everyone did the proper thing IAW their particular protocols and scopes of practice, but that doesn't make it any easier. We have several regular patients who are all 100+, bedridden, confused/demented, PEG tubes for nutrition, etc. On certain occasions we have transported them for appointments and they, frankly, weren't doing too well that day. When I discreetly questioned family members regarding DNR orders, the reply is invariably the same "Oh, NO! You have to do everything you can to save Mama!! She simply can't be allowed to pass; we'd be lost without her. Do EVERYTHING you can to make sure she keeps living!" I'm not second-guessing the family's wishes; it's their right to decide on resusitation efforts for their loved one. That said, it would break my heart to have to do CPR on a 65lb double amputee who is 105 years old. Yes, I would do it to the best of my ability, but my point is that sometimes family has a hard time letting go, even in the midst of numerous reasons that they should. Again, it was a rotten situation, but you did the best you could. Just know there are others out there facing those same dilemmas every day, and they will only get to be more and more common as our population ages.

 

[Arkymedic]

- I do not agree with Flight LP here with one thing. While my system would have never let us "pull the tube", if your medical control doctor does advise you to do this as per family decision... it is not murder. Failing to follow this decision would be FELONY ASSAULT AND BATTERY.

Very good thought there! It's a hard pill to swallow! In 13.5 years of my career, this has to be the toughest call ever for me. Thank you all for your comments on this one. Everything has been helpfull! It's a hard thing to except that a patient was brought backl by my hands and then she also died by my hands! My shift alone has been slammed very hard recently... I know for the last 2 months! I'm just wondering when it's going to calm down for a bit! I've had a code each shift, 3 saves, 2 died after the save, I've had to fly out two patients, one motorcycle fatality last weekend, and this. Every patient I've picked up in the two months has been either circleing the drane or already down it! I know I'm in this business for that... however... sometimes a provider needs a few stomped toe calls to keep thier sanity! We see way too much sometimes in this business. One of my codes was a 17 year old trauma code from an MVC. Just when does it stop? Believe it or not, we got her back... she did die later on the OR table, but not on us! It's just touch sometimes. Thank you all for being there!

As for our med control, they are very open to our treatments. We have protocols, but all meds are standing orders. They trust us too much sometimes. If we want to call a code in the field, they are usually ok with it... whatever we want to give... they trust us. We have to be good. It opens us up for a law suit for them to be so open.[/QUOTE]

The Asst. Director at the Ark Fire Academy told us something back in 2003 in my rookie school something that has always stuck with me "You are responding to something that YOU did not cause. All you can do is improve the situation for the individual".

 

[triemal04]

Like everyone has said, you did absolutely nothing wrong and shouldn't be feeling bad in any way about your actions or the outcome. With no valid DNR and the family requesting everything, you've got no choice but to work them. For what happened after...call the doc. Just like you did. And if the family had intially wanted resucitation withheld, do the same thing. The pt is under hospice care for a reason, and hopefully the family is well aware of their wishes.

I had a similar case a couple of years ago. Elderly male (late 80's) in an assisted living facility, found with a GCS-6, p-42, BP-unobtainable, rr-10, ecg-3rd degree AV Block. Both the wife and manager of the facility said he had a DNR but neither could find it. The wife did not want him worked. OLMC was contacted and everything was made real clear to her; that if nothing was done this was it for him, when she didn't change her mind the doc had us transport him to the hospital with BLS only, no CPR if it came to that. He died about 2 minutes after being put into the car.

It's strange to watch someone die when we're trained to do something about it, but I believed (and still do) that that is what the pt would have wanted.