# 83 y/o N/V + Fever



## rhan101277 (Nov 29, 2013)

I wanted to get some feedback and see how other might treat this patient I had.  You are dispatched to a local nursing home for above complaint.

Pt in a DNR

You arrive and obtain the following vitals:

Staff report temp 102.2 axillary, 88% SPo2 room air
pt baseline gcs 9, non verbal
monitor shows sinus tach 130
SPo2 77% on room air, 38RR
skin hot to touch
146/86 b/p
120cbg
L/S rhonchi b/l
red rash noted in a few spots on the legs and chest, staff report this has been there for two days.

In route patient has PSVT with rates as high as 180 and back down to 100 and runs of vtach.

How would you treat this patient?


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## Handsome Robb (Nov 29, 2013)

Fluids, treat dysrhythmias PRN but I'd try and stay away from it if I could. Titrate O2 to >92% SpO2. Sounds like sepsis. Tachypnea, tachycardia, febrile, low Spo2. You said baseline GCS 9. We're they at their baseline or more altered than usual? There's at least 4 SIRS criteria points right there, depending on their mentation might have 5.


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## EMT B (Nov 29, 2013)

12 lead, IV, Med Control for 4mg Zofran ODT, Fluid Bolus, if the patient is able to swallow then 1g Tylenol PO for fever, and get the O's flowing via nasal prong capnography at 4LPM. 

Robb, why would you try to stay away from treating the PSVT?


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## rhan101277 (Nov 29, 2013)

the patient started on Levaquin on 11/28 the rash the patient had that was there for "2 days" spread like wildfire and looked like hives all over.  I think pt was allergic to levaquin, but this was the least of his worries and I didn't notice it spread until we were at the hospital.

18g Left FA established with fluids wide open in route.
ETCO2 done
12 lead on back burner, you had to worry about suctioning


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## chaz90 (Nov 29, 2013)

EMT B said:


> Robb, why would you try to stay away from treating the PSVT?



I'll bite on this if Robb doesn't mind.  For me, I'm not overly concerned with short runs of tachyarrythmias as they seem to be self-terminating. The patient also has a (perhaps suspiciously) good BP per the OP. Baseline GCS of 9 and no mention of change in mental status makes it more difficult to assess possible AMS related to the fever or runs of tachycardia. Also, how were these runs of PSVT and V-Tach differentiated during transport?

As far as my treatment, I'd go with PIV access, O2 titrated to SpO2 (while also evaluating validity of SpO2 values by evaluating peripheral perfusion and the waveform), re-evaluating that possibly suspicious BP, IV fluids, lactate reading, 12 lead. I wouldn't touch the arrhythmias with meds unless they became sustained or hemodynamically compromising.

On a side note to EMTB, why would you want to administer ODT Zofran? Did I miss something in the presentation? Furthermore, I don't see the reason for ODT if you already have an IV established with fluids flowing.


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## teedubbyaw (Nov 29, 2013)

I wouldn't be inclined to treat these arrhythmias, either. Underlying cause is what's setting them off, IMO.


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## EMT B (Nov 29, 2013)

nausea and vomitting im going to give zofran. i can only give ODT...i cant draw it up because med director is stupid 


sounds like ODT is contraindicated anyways because need for suctioning. sounds like i wouldn't be giving the tylenol either. 

only drugs i can "push" are d50 narcan and epi 1:1k. oral i can give normal stuff plus tylenol and zofran


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## Handsome Robb (Nov 29, 2013)

You know what Chaz? I do mind!!! 



EMT B said:


> 12 lead, IV, Med Control for 4mg Zofran ODT, Fluid Bolus, if the patient is able to swallow then 1g Tylenol PO for fever, and get the O's flowing via nasal prong capnography at 4LPM.
> 
> Robb, why would you try to stay away from treating the PSVT?



Because like Chaz said they're self terminating. Also the "P" in PSVT stands for "paroxysmal" which means the dysrhythmia is abruptly starting and stopping. My first guess is that it would be a hypovolemic induced PSVT. Now knowing it was an allergic reaction relative hypovolemia can certainly cause tachydysrhythmias.

The squiggles will just keep doing what you don't want them to do unless you fix the underlying problem. 

I was way off...figured the rash might be important.

Crackles must've been from aspiration, eh? Considering you mentioned suction.


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## rhan101277 (Nov 29, 2013)

When I first saw the rash, I am calling it that, I thought it would be an allergic reaction because they were hives.  I dismissed that when she said they were there for 2 days, but when we got to the ER they had gotten worse.  I did some reading online and several medications can cause rashes that can mimic an allergic reaction and still need to be treated as such.  Even if I had treated that rash it definitely wasn't my top priority.  I sure wasn't going to administer an albuterol treatment or solumedrol, if anything benadryl.

Sometimes you get calls that go beyond the textbooks.  Sepsis, fever and rash don't read the textbooks and sometimes they don't react as suspected.  This patient had a bounding pulse and moving air "ok" except for the rhonchi.  It becomes more complex when patients present with multiple issues.


Here is the thing about tachycardia, if you have a patient with a sustained rate of 160 who presents in this fashion w/ stable vitals try fluid first.  Figure out what is causing the rate problem.  Patients with fever often present with tachycardia and combined with dehydration, rates can be this high.  Pushing adenosine on this would probably cause a transient rate slowing and then it will immediately rise back up.  You could also cause the patient more harm and you might just be buying him/her a back-hoe for the grave.

Just because you can do something, doesn't mean it is the correct treatment.  I considered calling med control for assistance, but realized there is nothing they can have me do that I haven't already done.


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## VFlutter (Nov 29, 2013)

Sepsis/SIRS + ARDS. Fluids, lots of fluids. Bipap


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## Akulahawk (Nov 29, 2013)

Personally, I'd treat this patient with fluids. This patient is well down the sepsis pathway. I'd also titrate the oxygen to SpO2 >92%. What do I also notice... the patient is DNR. While I'm providing some fluid resus, the arrythmia may terminate due to better fluid status. If for some reason the patient isn't ventilating well, I would certainly consider CPAP as it's not "invasive" and isn't considered "assisting ventilation" in a way that violates a DNR order. I wouldn't give Zofran as there's no indication of N/V in this patient. Tylenol PO is likely "out" due to level of consciousness. If this actually is baseline for this patient, I would seriously wonder about whether or not this patient has a PEG or NGT for feeding. I wouldn't expect that a patient with a baseline GCS of 9 to be able to self-feed. If I have a standing order for Tylenol for fever, I would consider administering it PR...

If the rash looks like it's an allergic reaction, I may be able to provide some benadryl for it. However, this looks a LOT like SIRS/Sepsis to me at this point in patient that has a rash that may or may not be related.


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## Handsome Robb (Nov 29, 2013)

I'm wondering if this guy doesn't have more going on than just the reaction.

Definitely like Chase's theory of sepsis/SIRS + ARDS. 

I'm interested to hear what all they found besides the reaction.


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## chaz90 (Nov 29, 2013)

Also, the "rash" could instead be purpura of DIC...


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## Anjel (Nov 29, 2013)

chaz90 said:


> Also, the "rash" could instead be purpura of DIC...



That was my first initial thought when I read the scenario. It could be a bunch of different things, but that would fit.

I'm also going to agree with the boys. Monitor, fluid bolus, keep an eye on the dysrhythmias, but as long as the patients condition is stable, I am just going to beat feet to the ER.


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## Handsome Robb (Nov 29, 2013)

chaz90 said:


> Also, the "rash" could instead be purpura of DIC...



My first thought was mottling then I remembered that rhan knows what he's doing and would recognize mottling vs a rash.


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## Mariemt (Nov 30, 2013)

A massive bladder infection will do all sorts of weird things to the elderly, I run into this a lot . I would suspect sepsis with infection causing the low GCS.

I agree with fluids. Monitoring, transport.


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## Mariemt (Nov 30, 2013)

Robb said:


> My first thought was mottling then I remembered that rhan knows what he's doing and would recognize mottling vs a rash.


 my experience is mottling is up to several hours, but not days. 
That is just personal experience, not by the book.


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## rhan101277 (Nov 30, 2013)

Yeah I am going to try to find the outcome.  I treated with fluids, high flow oxygen and diesel gas.  I did get to thinking I am glad I went to a good paramedic program, because for some it would be easy to jump on adenosine or cardioversion.  I always try to remember if I have any doubt to the correctness of my action, I will call med control for consult.  It is isn't asking "mother may i" its a different set of eyes with much more knowledge looking at the problem.

The nurse said it was baseline but I saw no peg tube and I even doubted he could pass a swallow test.  Sometimes getting reports from nursing homes can be hit/miss.


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## Handsome Robb (Nov 30, 2013)

Mariemt said:


> my experience is mottling is up to several hours, but not days.
> That is just personal experience, not by the book.



I was referring to the mottling that develops in hypoperfused tissues in severely septic patients. Not sure we're talking about the same thing. Mottling a late, and generally rather bad sign of hypoperfusion.


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## Rialaigh (Nov 30, 2013)

First I am going to talk to family if they are there or reachable by phone and ask what their plans for treatment are or try and get a general feeling of how much they want done. 

2. O2 up to a non rebreather, not putting this patient on Cpap unless the family is specifically requesting that "Everything" be done. 
3. Iv and a bag of fluids.


Nothing else, certainly no medications. Average of a 25 minute ride to the hospital and the ER physician can talk to the family and see if they want antibiotics or anything or just a simple o2 mask and some morphine. 

This patient is sick, based on presentation very very few of the people with those vitals survive long, especially if there is an extensive medical history (which I would suspect). Hopefully the family is at peace, time to let the body do what it is supposed to do.


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## VFlutter (Nov 30, 2013)

Mariemt said:


> my experience is mottling is up to several hours, but not days.
> That is just personal experience, not by the book.



Ever see an acute arterial occlusion? Mottling can happen in minutes. 



teedubbyaw said:


> What does a DNR have to do with treatment of this patient in her current state?



I am a huge advocate for non-aggressive treatment and palliative care however with most DNR patients the expectation is that they receiving aggressive standard care up until the point of cardiac arrest. Unless the patient is hospice.

Personally, I do not think the paramedic should be making calls to contact the family about treatment decisions. That is the MDs responsibility and they are the ones who can legally take verbal consent to stop treatment.


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## triemal04 (Nov 30, 2013)

Rialaigh said:


> First I am going to talk to family if they are there or reachable by phone and ask what their plans for treatment are or try and get a general feeling of how much they want done.
> 
> 2. O2 up to a non rebreather, not putting this patient on Cpap unless the family is specifically requesting that "Everything" be done.
> 3. Iv and a bag of fluids.
> ...


This.

Before any type of care is rendered it needs to be determined how much care this patient actually wants.  Make no mistake, that is entirely part of the job of a paramedic, and must be done first.


rhan101277 said:


> Pt in a DNR


Tell me more about the patient's DNR.  Does it specify any other care beyond "no CPR?"  Since he has a DNR, what did his advance directives, if any, say.


> pt baseline gcs 9, non verbal


This sounds like someone who is very likely to have a power of attorney.  What did they say when you contacted them?

I'm sure the OP did all this, but it remains that this needs to be done in this situation.


Chase said:


> I am a huge advocate for non-aggressive treatment and palliative care however with most DNR patients the expectation is that they receiving aggressive standard care up until the point of cardiac arrest. Unless the patient is hospice.
> 
> Personally, I do not think the paramedic should be making calls to contact the family about treatment decisions. That is the MDs responsibility and they are the ones who can legally take verbal consent to stop treatment.


Actually, many states have various levels of care that go with a DNR; they DO NOT always recieve aggressive care until their heart stops, nor is that always in their best interest.

Contacting a patient's POA (if there is one) is absolutely something that every paramedic should be doing, and should be comfortable in doing.


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## teedubbyaw (Nov 30, 2013)

triemal04 said:


> This.
> 
> Before any type of care is rendered it needs to be determined how much care this patient actually wants.  Make no mistake, that is entirely part of the job of a paramedic, and must be done first.
> 
> ...



This patient has a treatable illness. She is unlikely to code en route. Treat and go. No reason to try and play phone tag with family and scare them.


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## Carlos Danger (Nov 30, 2013)

teedubbyaw said:


> This patient has a treatable illness. She is unlikely to code en route. Treat and go. No reason to try and play phone tag with family and scare them.



Yeah, this is how I see it as well. 

The nursing home staff should be able to give basic info, i.e., supply you with a DNR or other advance directive as part of the transfer paperwork.

Beyond looking through the paperwork quickly and asking the referring "does this patient have an advance directive?", I wouldn't waste time "investigating". This is a sick patient who needs to be managed and transported. Normally the nursing home would already have called the family and let them know what is going on, long before transport arrives.

Unless told otherwise, I think it is always safe to assume that normal care is the expectation.


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## NomadicMedic (Nov 30, 2013)

This is why a specific MOLST/POLST form needs to become a standard document in patients with advanced directives in place. Playing the guessing game with nursing home staff and family is certainly not in the patient's best interest. However, neither is starting treatments that may be discontinued on arrival at the ED. A clearly defined "menu" of patient approved treatments and interventions should be included in the packet of every long term care patient.


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## mycrofft (Nov 30, 2013)

Stray shots:

1. Remember the elderly (especially the very elderly…say, a couple years past me) don't always exhibit a fever as promptly as youngsters do.

2. Not uncommon for elderly septic, especially pneumonia, to have disturbances of mentation, delirium, and lapsing in/out of consciousness.

3. We have a new paradigm. Just as "all bleeding stops eventually", then "In a DNR case, all arrythmias end eventually".

4. Nausea and vomiting….electrolytes?  Exhaustion?(Says N/V on the thread title but not referred to in the thread's body by the OP).


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## Handsome Robb (Nov 30, 2013)

FWIW I make contact with POAs on a daily basis at work.

Even in a time critical situation there's time to at least make an attempt to get a hold of them on the phone. Doesn't take that much time to have staff find the number for you and then to dial it and leave a message if no answer.


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## Clipper1 (Nov 30, 2013)

Rialaigh said:


> First I am going to talk to family if they are there or reachable by phone and ask what their plans for treatment are or try and get a *general feeling *of how much they want done.
> 
> 2. O2 up to a non rebreather, not putting this patient on Cpap unless the family is specifically requesting that "Everything" be done.
> 3. Iv and a bag of fluids.
> ...



You have just confirmed why patients, families, DPOAs and physicians are reluctant to sign off on DNRs.   They fear the DNR will be interpreted as Do Not Treat and the patient will suffer needlessly.  

You have no definitive diagnostic data to base your decision. You are also asking the family or DPOA to call it quits for something which could easily be treated and the patient returned to baseline within 24 hours. This is not a "general feeling" but a decision which could end this person's life early for a treatable cause.  You are also making the family make a decision for not doing medical treatment which they probably have never heard of like CPAP.  They are not physicians and do not know if antibiotics and fluids would help especially if there is no lab work or other diagnostics to back up this decision.  This is not an informed decision and the patient's heart has not stopped. With your phone call you are probably directing them to make decisions based solely on your own personal feelings and not the appropriate medical information. You may have hated all of those nursing home calls and now is your opportunity for a little "mercy" life ending or whatever you might prefer to call it.   You need to defer to a physician and treat the patient appropriately along with not wasting time. 

I am also going to suggest you take a geriatric medical emergencies class to learn more about how the most common illnesses can present poorly in the elderly but also can be easily treat.


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## teedubbyaw (Nov 30, 2013)

Well said. Editing this post so I don't get an infraction for saying what should be said about a questionable person.


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## VFlutter (Nov 30, 2013)

Robb said:


> FWIW I make contact with POAs on a daily basis at work.
> 
> Even in a time critical situation there's time to at least make an attempt to get a hold of them on the phone. Doesn't take that much time to have staff find the number for you and then to dial it and leave a message if no answer.



Do you feel like you have the medical knowledge and experience to confidently tell a patient'a family that medical treatment is futile? Do you think that you have the adequate information in the field to make that call? Do you have a solid understand of what happens to these patients after the ED? This is not an attack but rather a legitimate question. 

I am all for calling and clarifying wishes but if you are pushing them towards a certain treatment plan then you are in a grey area that I think is best left to the Physican. I am constantly amazed what 24-48hrs of IV fluids and antibiotics can do for some of these patients.


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## teedubbyaw (Nov 30, 2013)

"Grandma is running a fever and has a rash. Would you like me to treat her?"


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## Handsome Robb (Nov 30, 2013)

I don't think there's any question on if we treat this patient. The question is how aggressive are we? 

Most SNF patients have an AD that defines what can and cannot be done during their care. If they don't call and ask. Be objective when you talk to family and be simple, they don't need a long complex explanation, "your father/mother has a high temperature and a low BP which indicates a severe infection that may have spread to their blood stream. Would you like us to use medicine to raise their blood pressure if we need to? Would you like us to place a breathing tube if needed? Would you like the patient transported to the hospital, if so, would you like them to give the patient antibiotics?"

It's that simple. 

I agree that many disease processes affect the elderly much more than younger patients however I think we can all agree that this patient is well down the SIRS/Sepsis pathway, if be willing to go as far as saying they're entering into decompensated phases of septic shock. The morbidity and mortality for elderly is poor then add severe co-morbidities and it gets even worse. Sure it could be something simple and that needs I be considered but when you hear hoofbeats think horses not zebras.


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## Clipper1 (Nov 30, 2013)

Robb said:


> It's that simple.
> 
> I agree that many disease processes affect the elderly much more than younger patients however I think we can all agree that this patient is well down the SIRS/Sepsis pathway, if be willing to go as far as saying they're entering into decompensated phases of septic shock. The morbidity and mortality for elderly is poor then add severe co-morbidities and it gets even worse. Sure it could be something simple and that needs I be considered but when you hear hoofbeats think horses not zebras.



That simple?

The SIRS/Sepsis pathway is for "survival" and decreasing morbidity. It is not intended to be used to tell the family to make a final decision.  But, you are also making "assumptions". The lactate may not be at a notable level yet. The electrolytes and fluid status could be the primary. 

If you have recognized all of this why are you not  doing so form of treatment rather than just trying to coax the family into making a decision which then can justify you not doing anything and an easy transport.

The zebras and horses comment is also very unfounded since medicine does not always fit nicely into the rather limited Paramedic text.


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## Tigger (Nov 30, 2013)

Clipper1 said:


> That simple?
> 
> The SIRS/Sepsis pathway is for "survival" and decreasing morbidity. It is not intended to be used to tell the family to make a final decision.  But, you are also making "assumptions". The lactate may not be at a notable level yet. The electrolytes and fluid status could be the primary.
> 
> ...



I think asking the family if they want invasive treatments performed on their loved ones is a legitimate question. I would much rather ask the family ahead of time "if their illness progresses to the x point they may require y intervention. Are you ok with this?"

This is not a justification for doing nothing. Far from it. This is trying to act in the patients best wishes.

Talk about assumptions.


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## Clipper1 (Nov 30, 2013)

Tigger said:


> I think asking the family if they want invasive treatments performed on their loved ones is a legitimate question. I would much rather ask the family ahead of time "if their illness progresses to the x point they may require y intervention. Are you ok with this?"
> 
> This is not a justification for doing nothing. Far from it. This is trying to act in the patients best wishes.
> 
> Talk about assumptions.



The DNR means somebody has spoken with the patient/family/DPOA *but* the family should also have some assurance they made the correct decision and that Paramedics will not provide treatment based on just a few vital signs still showing signs of life and no other diagnostics.  It is also not in the patient's best interest to withhold treatment for something which could be treatable.  Allowing someone to decline for something which is treatable is negligent regardless of the DNR. Calling a family member to condone this when you really have very little data should not allow you to have a get out of jail free card for what is mostly based on your personal beliefs and not medical diagnostics.  You can not call yourself a patient advocate unless you have more to go on. In this scenario, you do not nor do you in most situations you encounter in prehospital. You are assuming when you make this life ending diagnosis.


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## teedubbyaw (Nov 30, 2013)

Clipper1 said:


> Allowing someone to decline for something which is treatable is negligent regardless of the DNR.



I think this is the main point being conveyed. It seems some of you are looking at it as a whole, and not this particular patient. 

I think we can all agree that this patient is fairly stable. Let the hospital deal with the 'fine print.'


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## Handsome Robb (Nov 30, 2013)

Clipper1 said:


> That simple?
> 
> The SIRS/Sepsis pathway is for "survival" and decreasing morbidity. It is not intended to be used to tell the family to make a final decision.  But, you are also making "assumptions". The lactate may not be at a notable level yet. The electrolytes and fluid status could be the primary.
> 
> ...



Did I ever say that I coax families into anything? I take offense to that comment because I am far from lazy. The patient has a right to decisions about their care and if they're unable to make them and have appointed a POA that person has a right to make those decisions for them.

I didn't say anything about telling the family about the SIRS/Sepsis pathway. I said "your mother father has xx vitals that indicate a severe infection that *may* have spread to their bloodstream." How is that coaxing them into anything? I asked direct questions about specific treatments. If they answer with "do what you think is necessary" or another similar blanket statement I'll absolutely treat that patient to the standard of care without violating the DNR order or AD. 

I can very easily make a phone call while the FD and my partner work on getting a line and fluids going and get them moved over and packaged for transport. 

Fine it's a cliche comment. But are you going to look for the most complex diagnosis possible or are you going to look at the objective assessment in front of you and form a working diagnosis with the tools that you have? What does it change if this person has an easily correctable infection or advanced SIRS change about your treatment of this patient in this scenario?

It doesn't matter what the situation is the POA should always be contacted if there's something going on with the patient they're in charge of making decisions for. Routine or emergent.

It's very obvious you assume that no paramedic can possibly converse with a family member/POA in an objective manner.


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## Clipper1 (Dec 1, 2013)

Robb said:


> Did I ever say that I coax families into anything? I take offense to that comment because I am far from lazy. The patient has a right to decisions about their care and if they're unable to make them and have appointed a POA that person has a right to make those decisions for them.
> 
> I didn't say anything about telling the family about the SIRS/Sepsis pathway. I said "your mother father has xx vitals that indicate a severe infection that *may* have spread to their bloodstream." How is that coaxing them into anything? I asked direct questions about specific treatments. If they answer with "do what you think is necessary" or another similar blanket statement I'll absolutely treat that patient to the standard of care without violating the DNR order or AD.
> 
> ...



The POA is always contacted by the sending facility and then again by the rec'g facility. 

You are asking the POA to make a decision based solely on your assumptions and personal feelings without any data other than vitals to back it up and those vital signs could be from many other things.  


A patient also has the right to be treated. They did not sign away their right to be treated by signing a DNR. After reading this discussion, people probably should be afraid to sign a DNR. Patients have the right to not suffer needlessly and they have the right adequate medical treatment by the appropriate providers.

You do not violate a DNR by treating a patient who still has a heartbeat. DNR does not mean DO NOT TREAT.


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## Wheel (Dec 1, 2013)

Clipper1 said:


> The POA is always contacted by the sending facility and then again by the rec'g facility.
> 
> You are asking the POA to make a decision based solely on your assumptions and personal feelings without any data other than vitals to back it up and those vital signs could be from many other things.
> 
> ...



I don't think he ever said that a DNR means do not treat. He said he'd contact a POA for a pt who can't speak for themselves regarding their treatment, and that also has a DNR.


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## rhan101277 (Dec 1, 2013)

The patient had a DNR on the physician orders paperwork.  Not a normal kind of DNR w/ two physician signatures where it shows what they would or would not like done.  Families need to be made aware and nursing home staff aware that these exist/


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## Clipper1 (Dec 1, 2013)

rhan101277 said:


> The patient had a DNR on the physician orders paperwork.  Not a normal kind of DNR w/ two physician signatures where it shows what they would or would not like done*.  Families need to be made aware and nursing home staff aware that these exist*/



Those orders need to be clarified at the facility. Most facilities have their own forms.  But, this should have been done and you need to be checking with the nurse.


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## Rialaigh (Dec 1, 2013)

Clipper1 said:


> You have just confirmed why patients, families, DPOAs and physicians are reluctant to sign off on DNRs.   They fear the DNR will be interpreted as Do Not Treat and the patient will suffer needlessly.
> 
> You have no definitive diagnostic data to base your decision. You are also asking the family or DPOA to call it quits for something which could easily be treated and the patient returned to baseline within 24 hours. This is not a "general feeling" but a decision which could end this person's life early for a treatable cause.  You are also making the family make a decision for not doing medical treatment which they probably have never heard of like CPAP.  They are not physicians and do not know if antibiotics and fluids would help especially if there is no lab work or other diagnostics to back up this decision.  This is not an informed decision and the patient's heart has not stopped. With your phone call you are probably directing them to make decisions based solely on your own personal feelings and not the appropriate medical information. You may have hated all of those nursing home calls and now is your opportunity for a little "mercy" life ending or whatever you might prefer to call it.   You need to defer to a physician and treat the patient appropriately along with not wasting time.
> 
> I am also going to suggest you take a geriatric medical emergencies class to learn more about how the most common illnesses can present poorly in the elderly but also can be easily treat.




Families pretty well know if they want a loved one on a breathing machine of any kind. The only other thing in question here is field pressors, with an average transport time of 25 minutes I doubt I would hang these period because it will take that long to find out if the patient is responsive to fluid therapy. Based on current BP it is not even an issue. 

Whether the patient is a DNR or not has nothing to do with the fact that we are supposed to treat patients according to their wishes. And if they are unable to make a medical decision then according to the wishes of the POA or next of kin (if no POA). This person could be 30 years old with no previous medical problems, and if he is unable to make a medical decision and the POA does not want a breathing machine used or a tube placed...then it is my moral and legal responsibility to NOT do it. 

I am not asking this family to make a decision based on my feelings, I am asking them to make a decision based on their feelings. As far as saying there is no definitive diagnostic data...well...if you think a lactate is the end all then...start treating based on numbers and not patient presentation I guess..



Stop treating patients that DON'T want to be treated....there are way more of them out there than you would think...


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## VFlutter (Dec 1, 2013)

Rialaigh said:


> Stop treating patients that DON'T want to be treated....there are way more of them out there than you would think...



Then they should have never called EMS.


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## NomadicMedic (Dec 1, 2013)

Let's get back on topic. This is a scenario post, not a debate on DNR patients. It's a good discussion, but one that should continue in another thread.


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## Handsome Robb (Dec 1, 2013)

Clipper1 said:


> The POA is always contacted by the sending facility and then again by the rec'g facility.
> 
> You are asking the POA to make a decision based solely on your assumptions and personal feelings without any data other than vitals to back it up and those vital signs could be from many other things.
> 
> ...



Really?

A patient like this that comes into the ER is going to get  managed very conservatively until they get a hold of the POA and find out what they want. Do you really think an ER is going to go blasting away with imaging, diagnostics and lab studies on a patient like this without confirming that's what the family wants? There's a reason they go straight to the phone. How are we, as medical providers, any different? 

Also seeing as they generally make that phone call early on what do you think the doctor is basing their info that they're giving the family member off? Oh yea...vitals, HPI and a detailed physical exam.

Edit: sorry, just saw that last post...oops lol


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## mycrofft (Dec 1, 2013)

*83 y/o N/V + Fever​*



rhan101277 said:


> I wanted to get some feedback and see how other might treat this patient I had.  You are dispatched to a local nursing home for above complaint.
> 
> Pt in a DNR
> 
> ...



1. What specifically was on the "DNR"? No IV, no oxygen, no resuscitation, no transport? No what?

2. Was rash blanchable? Had the family taken the pt's temp lately? (Oddly, you could have them do it as laypersons if you aren't allowed to as an EMT, just attribute it to them).

3. How about EKG, oxygen per tolerated device, transport while clarifying this "DNR" situation? (25 min and a cell phone….what luxury).

4. If some treatment modes are revealed as ok to do, and the remaining time doesn't obviate them, then do them per protocols.

There are three concerns here. 1. What's wrong (directs tx and maybe communicable disease concerns ). 2. What can I legally and ethically do IN THIS PARTICULAR CASE? (directs tx and as a legal defense). 3. In the time given, can you make a difference or are you just satisfying your need to perform your skills?


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## Handsome Robb (Dec 1, 2013)

Personally the only thing in this specific scenario that I see that could mess with the DNR order is pressors or intubation. Depending on how it's worded an argument could be made against C/BiPAP because it could be considered mechanical ventilation.

The EMS management of this patient isn't going to change unless they decide that they don't want the patient transported or you have a very long transport time. 

There is no reason you can't place a NRB, get a line, start fluids and package the patient while you work on contacting the POA. How is that lazy or subpar care? Please explain that to me. This is an "ALS" transport if hey decide they don't want us to do anything and just transport or if they say they want you to do everything. It's my call, I do not care if I sit and chart or if I aggressively treat the patient. Honestly I'd prefer the latter. I hate sitting in the back with a patient that is sick and suffering and not being able to do anything to help them.

Something to address the allergic reaction. It's not uncommon for these patients to have Benedryl prescribed to the PRN for itching or rashes so if you want to treat the rash with IV Benedryl and have a protocol to do so there's no issue there. Even if they don't have an Rx for it I don't have an issue treating it, provided you can support an allergic reaction what says you can't give it under your protocol? After all everyone in here seems to think we think DNR means do not treat...


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## FLdoc2011 (Dec 1, 2013)

Robb said:


> Really?
> 
> A patient like this that comes into the ER is going to get  managed very conservatively until they get a hold of the POA and find out what they want. Do you really think an ER is going to go blasting away with imaging, diagnostics and lab studies on a patient like this without confirming that's what the family wants? There's a reason they go straight to the phone. How are we, as medical providers, any different?
> 
> Also seeing as they generally make that phone call early on what do you think the doctor is basing their info that they're giving the family member off? Oh yea...vitals, HPI and a detailed physical exam.



Actually a patient like this that comes into the ER is going to get treated aggressively at first unless someone comes along and the patient is either made CMO or the POA states they don't want a certain intervention.  An unstable patient is going to be treated first before the physician takes their time to find some family member and talk them through the different options.   

In short, they're going to err on the side of treating that patient instead assuming anything.   The liability otherwise is too great.    

Same thing when I'm dealing with someone crashing in the ICU,  unless they are CMO or I know beforehand specific wishes I have to be aggressive with them until I hear otherwise.   As soon as I'm able of course I'm going to get in touch with someone to see how much they want done but it won't be at the sake of waiting to intervene on a crashing patient.


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## Handsome Robb (Dec 1, 2013)

FLdoc2011 said:


> Actually a patient like this that comes into the ER is going to get treated aggressively at first unless someone comes along and the patient is either made CMO or the POA states they don't want a certain intervention.  An unstable patient is going to be treated first before the physician takes their time to find some family member and talk them through the different options.
> 
> In short, they're going to err on the side of treating that patient instead assuming anything.   The liability otherwise is too great.
> 
> Same thing when I'm dealing with someone crashing in the ICU,  unless they are CMO or I know beforehand specific wishes I have to be aggressive with them until I hear otherwise.   As soon as I'm able of course I'm going to get in touch with someone to see how much they want done but it won't be at the sake of waiting to intervene on a crashing patient.



I'm not saying that the ER does nothing, I guess I didn't communicate that well.

Every single time I've brought a patient, who has a DNR that isn't specific to what is and is not allowed, that's hemodynamically unstable into the ER the ERP starts treating while the case manager works on making contact with the POA. They're not going straight to intubation, central lines, pressors, they're starting early goal directed therapy in the least invasive way possible. Drawing labs, maybe NIPPV if it's indicated, a second line, imaging. Things like that. Hell they might even start antibiotics, I'm not sure. 

I've not once seen anyone say write this person off, don't treat them, they're dead.


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## FLdoc2011 (Dec 1, 2013)

Robb said:


> I'm not saying that the ER does nothing, I guess I didn't communicate that well.
> 
> Every single time I've brought a patient, who has a DNR that isn't specific to what is and is not allowed, that's hemodynamically unstable into the ER the ERP starts treating while the case manager works on making contact with the POA. They're not going straight to intubation, central lines, pressors, they're starting early goal directed therapy in the least invasive way possible. Drawing labs, maybe NIPPV if it's indicated, a second line, imaging. Things like that. Hell they might even start antibiotics, I'm not sure.
> 
> I've not once seen anyone say write this person off, don't treat them, they're dead.



Yea obviously intubation is off the table with the DNR known but everything else really isn't different from how they'd approach and treat someone who came in with a similar presentation but no DNR.   Even in those situations central lines and pressors aren't immediately started until at least some basic work up.     My point is mainly this guy being a DNR, besides obviously being a "no code" and no intubation, doesn't really change how he should be approached from an initial treatment perspective.   For the most part it's not going to change how I work him up or my initial management.   Even a central line or bipap is not off the table.


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## FLdoc2011 (Dec 1, 2013)

And definitely wasn't saying or implying that you were saying do not treat.   Just speaking to you saying how this patient would be initially treated conservatively in the ED.     In my opinion this person is treated no different from any other person who comes in with a similar picture, except for intubation or running a code.   

We may have different definitions of "conservative" care as well.


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## triemal04 (Dec 1, 2013)

Chase said:


> Then they should have never called EMS.


\
I can't believe you actually said that.  Unless...you're joking, right?  I mean, there had to be heavy sarcasm there that just isn't coming across.

How about this for everyone?  This is a fairly standard POLST that is used in several states in very similar versions.  Please read the ENTIRE form before going on.
https://www.wsma.org/Media/Patients-pdfs/POLST-PrintDownload.pdf

If the OP's patient had declared themself a "DNR with comfort measures only" and had decided against antibiotics and tube feeding...how exactly would he be treated?


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## rhan101277 (Dec 5, 2013)

mycrofft said:


> *83 y/o N/V + Fever​*
> 
> 
> 
> ...



This was a DNR on a physicians order sheet not a standard DNR where items they want or don't want done are checked.  If it is on a order sheet I am going to honor it after I verify w/ staff.


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## Clipper1 (Dec 5, 2013)

triemal04 said:


> \
> 
> If the OP's patient had declared themself a "DNR *with comfort measures only" * and had decided against antibiotics and tube feeding...how exactly would he be treated?



The scenario was not "with comfort measures".



rhan101277 said:


> Pt in a DNR



But, if it had been "with comfort measures only" I would hope you would treat this patient with comfort measures which includes pain medications and oxygen if that is what the situation calls for clinical signs which means more than just an SpO2 check.  If your protocols allow for nebulizing fentanyl or morphine that is also an option for a patient expressing shortness of breath.


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## VFlutter (Dec 5, 2013)

triemal04 said:


> \
> I can't believe you actually said that.  Unless...you're joking, right?  I mean, there had to be heavy sarcasm there that just isn't coming across.
> 
> How about this for everyone?  This is a fairly standard POLST that is used in several states in very similar versions.  Please read the ENTIRE form before going on.
> ...



No, I am not joking. That was a response to the comment...


Rialaigh said:


> Stop treating patients that DON'T want to be treated....there are way more of them out there than you would think...



If the patient and/or patient's family truly does not want treatment as in "Comfort Measures Only" then they should not be calling EMS and certainly not be transporting to the hospital. Most of these type of patients have home health and hospice care. There is nothing we should be doing for these patients, even IV fluids are prolonging the dying process. 

However If the patient just has a DNR that is not specific other than no CPR/Intubation then by all means call 911 and transport. My treatment for that patient is no different than a full code patient. I do not assume that a DNR patient wants as little done as possible, as he implied. I assume the opposite, that they want aggressive treatment up until the point of cardiac arrest and want all reasonable interventions to prevent a cardiac arrest. 

I will try to scan a copy of our DNR order form. The wording is similar to what I just described "Aggressive treatment will be provided...". 




triemal04 said:


> If the OP's patient had declared themself a "DNR with comfort measures  only" and had decided against antibiotics and tube feeding...how exactly  would he be treated?



They should not be treated nor transported. They should be given their comfort medications and that is it. What do you think we are going to do for them when they get to the hospital?


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## Clipper1 (Dec 5, 2013)

Chase said:


> They should not be treated nor transported. They should be given their comfort medications and that is it. What do you think we are going to do for them when they get to the hospital?



That would depend on the reason called. Some cancer and AIDS patients are in hospice for comfort care but still get a limited amount of treatment such as replacing an infected port or PICC or even foley which could be causing discomfort.  The idea is for "comfort" throughout the dying process and not to allow what can easily be corrected to cause more discomfort.

But, I agree if the family called 911 they may have a good reason and a family member can fight a DNR. Sometimes they are the DPOA and sometimes they are not. This is why we have Ethics Committees and Physicians with legal advisors on call.


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## VFlutter (Dec 5, 2013)

Clipper1 said:


> That would depend on the reason called. Some cancer and AIDS patients are in hospice for comfort care but still get a limited amount of treatment such as replacing an infected port or PICC or even foley which could be causing discomfort.  The idea is for "comfort" throughout the dying process and not to allow what can easily be corrected to cause more discomfort.



Agreed but does that require an ER visit or hospital stay? (Aside from the PICC/Port) If the patient has absolutely no assistance then sure but the majority of these patients, if not in a LTAC or SNF, will have some type of home health care. It can, and should, be handled outside of the acute care setting.


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## Clipper1 (Dec 5, 2013)

Chase said:


> Agreed but does that require an ER visit or hospital stay? (Aside from the PICC/Port) If the patient has absolutely no assistance then sure but the majority of these patients, if not in a LTAC or SNF, will have some type of home health care. It can, and should, be handled outside of the acute care setting.



True but not all patients follow a recipe. Other body parts can break either bones (not necessarily from falling) or become diseased. We had one teenager at the beginning of hospice care who got a very painful tooth abscess which required extraction in the hospital. Another got appendicitis which really presented a dilemma.

This is a great discussion topic which I would be willing to continue on a nursing forum with you and others.


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## triemal04 (Dec 5, 2013)

Chase said:


> No, I am not joking. That was a response to the comment...
> 
> If the patient and/or patient's family truly does not want treatment as in "Comfort Measures Only" then they should not be calling EMS and certainly not be transporting to the hospital.


I don't mean to be rude, but you clearly do not understand why people call 911, who is calling, or what type of "comfort care" may be needed.  Many people call because they aren't sure of what to do, are panicking, don't know what the actual patient wants, or because they are required to (for someone living in an assisted-living center for instance).  While the actual patient may not want care, (or even need care in some cases) the simple fact that 911 was called does not in any way, shape, or form mean that they have consented to treatement.  Rialagh is very right; we need to stop treating people who don't want treatement.

This of course ignores the fact that "comfort care" is very much something that we can provide to many patients, and should when appropriate.  Sometimes this very well may mean that the patient is taken to the hospital.




> Most of these type of patients have home health and hospice care.


I'm sorry, but this is patently, and blatantly false.  Many, many, many people have a DNR with comfort measures only and are leading normal lives without any sort of hospice or in home care, nor do they need that type of care.  They simply know that they want to die peacefully and naturally when it happens.  As is very much their right.



> I will try to scan a copy of our DNR order form. The wording is similar to what I just described "Aggressive treatment will be provided...".


Please do.  I would be very interested to read the entire thing.


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## VFlutter (Dec 6, 2013)

triemal04 said:


> I'm sorry, but this is patently, and blatantly false.  Many, many, many people have a DNR with comfort measures only and are leading normal lives without any sort of hospice or in home care, nor do they need that type of care.  They simply know that they want to die peacefully and naturally when it happens.  As is very much their right.



Many, Many, Many people? Maybe it is more prevalent in your area however I have never seen a single patient come in with a "Comfort Measures Only" DNR that was leading anything close to a "normal life". I have seen many people who have DNRs that come in who are quite independent and relatively healthy, but we are talking about two totally different things. I have also never discharged a patient home on comfort measures without some type of in-home care. Which I do on a weekly basis with many of our end stage patients. 

By the definition of "Comfort Measure Only" DNRs it declines any life prolonging treatments. They will not receive IV fluids, IV abx, or any form of treatment other than pain/anxiety/etc. In reality they are sent to the lowest level of care bed available and either die or get discharged back to where they came from. 

I do not know many people who are living normal lives who choose to die from a UTI or would refuse treatment for an allergic reaction. But obviously it seems that you know more than I do.


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## triemal04 (Dec 6, 2013)

Chase said:


> Many, Many, Many people? Maybe it is more prevalent in your area however I have never seen a single patient come in with a "Comfort Measures Only" DNR that was leading anything close to a "normal life". I have seen many people who have DNRs that come in who are quite independent and relatively healthy, but we are talking about two totally different things. I have also never discharged a patient home on comfort measures without some type of in-home care. Which I do on a weekly basis with many of our end stage patients.


You need to step outside your bubble for a bit and realise that there is more to medicine than your part, and things that you won't deal with.



> I do not know many people who are living normal lives who choose to die from a UTI or would refuse treatment for an allergic reaction.


Which is the beauty of these things; patients may change their mind at anytime they choose.  And when told that they have a relatively minor and easy to treatement problem, many do.



> But obviously it seems that you know more than I do.


I see more patients in much more varied settings than you do.  There are plenty of patients that I see that, because of their choices, will never be seen by anybody who works is a hospital.  So yes, in this situation I DO know more than you.

Don't make this a **** measurin contest, ok.


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## Clipper1 (Dec 6, 2013)

triemal04 said:


> Which is the beauty of these things; patients may change their mind at anytime they choose.  And when told that they have a relatively minor and easy to treatement problem, many do..



But such as in the  scenario here, the person might be unresponsive from a UTI which could be easily treated. This is not uncommon in the elderly. However, as suggested by some here, the Paramedic might call the family and call it quits.  The patient may not have wanted to have their life terminated for a UTI and may have accepted treatment if responsive. Her heart had not stopped. 



triemal04 said:


> I see more patients in much more varied settings than you do.  There are plenty of patients that I see that, because of their choices, will never be seen by anybody who works is a hospital.  So yes, in this situation I DO know more than you.
> 
> Don't make this a **** measurin contest, ok.



You PICK UP patients in various settings but you don't always see what happens to them in the hospital.  You also don't see the patients brought in by other ambulances or by families.   How many patients are in the hospitals you deliver to on any given day? How many of those patients are yours? How many kids do you think are "comfort care" in your area that you know of?  Can you describe the hospitals and Hospice Palliative care protocols in your area?  What training do you have in Palliative care and Ethics?  Have you ever been on an Ethics meeting to determine the end of life process and the palliative care for a patient?  Have you actively participated in end of life by withdrawing life support? This does not mean stopping a code.


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## Carlos Danger (Dec 6, 2013)

triemal04 said:


> I don't mean to be rude, but *you clearly do not understand why people call 911*, who is calling, or what type of "comfort care" may be needed. * Many people call because they aren't sure of what to do, are panicking, don't know what the actual patient wants, or because they are required to* (for someone living in an assisted-living center for instance).



Huh? Chase said that if the patient didn't want to be treated, then EMS should never have been called.......he didn't say people NEVER call EMS for these things. Saying that something _shouldn't _happen is not the same thing as saying something _doesn't_ happen. Is it?

Perhaps these are reasons why people DO call EMS, but are they reasons why they SHOULD call EMS? I don't think so. Chase was right. People shouldn't call EMS in these situations. Just because they sometimes panic and do so doesn't mean we should promote it.

Now if there is intractable pain or something that isn't being effectively managed, then that's different. But even then, the best course is probably to get new orders from whoever is writing them, if that is an option.

If you don't want your car towed to an auto mechanic, you don't call a tow truck. If you don't want to be treated at a hospital, you don't call EMS. Pretty simple.





triemal04 said:


> This of course ignores the fact that *"comfort care" is very much something that we can provide to many patients*, and should when appropriate.  Sometimes this very well may mean that the patient is taken to the hospital.



So what is this magical "comfort care" that you can provide, that the nursing home staff and palliative care team cannot? 

Any patient that has been made "comfort care" is already being managed by a hospice or palliative care team. This patient in question was already in a nursing facility and already has orders and is already being managed by a physician. They should be able provide for his comfort needs. 

Do you really think the patient would be more "comfortable" being stuffed into an ambulance and taken to the hospital where he'll lay in a noisy, brightly lit room for a day or so while the doctors figure out what to do with him and eventually just send him back to his nursing home, and then send his family a hefty bill for TWO ambulance transports and a work up at the hospital? That is pretty much exactly what would happen if you took a patient to the hospital who wants only comfort care.


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## Clipper1 (Dec 6, 2013)

Halothane said:


> Any patient that has been made "comfort care" is already being managed by a hospice or palliative care team. This patient in question was already in a nursing facility and already has orders and is already being managed by a physician. They should be able provide for his comfort needs.



That is not correct. Unfortunately comfort care does not automatically come with a hospice or palliative care team. Some hospitals don't have palliative care teams and it is the luck of the draw for the patient if they get a doctor who understands "comfort care".  Different facilities have different protocols and levels of care they can provide. Nursing homes without a palliative care unit for exception to the state guidelines for the care provided are very, very limited for the medications they can provide. The same with sub-acutes with ventilator patients. SNFs are a little better.  But then placement into a facility becomes a wallet or insurance biopsy which appears to be your concern also.  Sometimes it is best to transport to a hospital when these patients' pain and comfort can no longer be managed in the nursing home. Other health care providers have to watch the suffering all shift while you are just there for 15 minutes to voice your "opinion".




Halothane said:


> Do you really think the patient would be more "comfortable" being stuffed into an ambulance and taken to the hospital where he'll lay in a noisy, brightly lit room for a day or so while the doctors figure out what to do with him and eventually just send him back to his nursing home, and then send his family a hefty bill for TWO ambulance transports and a work up at the hospital? That is pretty much exactly what would happen if you took a patient to the hospital who wants only comfort care.



Some hospitals now have hospice room set up for the comfort of the family and patient. These patients are suffering or at least give a strong appearance of suffering with a great deal of care required to alleviate it. Some also are difficult to place in any care facility due to the meds. Some are not a candidate for home since the family's training for all of the devices will take longer than death itself.  Some families who opted to take the patient home thought they were doing the best thing but didn't realize all the adjustments which would be needed physically and emotionally in a household. You really should not hold it against the patient or the family for this.  

And some call 911 when they feel helpless. It is difficult to watch a loved one die and not be able to control their discomfort.  You can talk big but if your child or wife was crying out in pain and the meds available were not working would you really care what it costs to transport them back to the hospital to get the pain under control?  Some also make assumptions that hospice and nursing homes are only for the very old who probably need to die but that is simply not true. Nor should you make assumptions that a facility can provide everything needed with just a doctor's order.  Check your own state and see how many different levels of facilities there are and what can or can not be done in each.   A Paramedic is also very limited and might only be able to do something for the short term but chances are the medications they carry are the same as the nursing home with the same limitations. This is why transport might be required rather than leaving a patient to suffer and not get the opportunity to be placed in a facility which can provide a higher level of comfort.


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## Carlos Danger (Dec 6, 2013)

Clipper1 said:


> That is not correct. Unfortunately *comfort care does not automatically come with a hospice or palliative care team.* Some hospitals don't have palliative care teams and it is the luck of the draw for the patient if they get a doctor who understands "comfort care".  Different facilities have different protocols and levels of care they can provide. *Nursing homes without a palliative care unit for exception to the state guidelines for the care provided are very, very limited for the medications they can provide.* The same with sub-acutes with ventilator patients. SNFs are a little better.  But then placement into a facility becomes a wallet or insurance biopsy which appears to be your concern also.  *Sometimes it is best to transport to a hospital when these patients' pain and comfort can no longer be managed in the nursing home.* Other health care providers have to watch the suffering all shift while you are just there for 15 minutes to voice your "opinion".
> 
> *Some hospitals now have hospice room set up for the comfort of the family and patient*. These patients are suffering or at least give a strong appearance of suffering with a great deal of care required to alleviate it. Some also are difficult to place in any care facility due to the meds. Some are not a candidate for home since the family's training for all of the devices will take longer than death itself.  Some families who opted to take the patient home thought they were doing the best thing but didn't realize all the adjustments which would be needed physically and emotionally in a household. You really should not hold it against the patient or the family for this.
> 
> *And some call 911 when they feel helpless.* It is difficult to watch a loved one die and not be able to control their discomfort.  You can talk big but if your child or wife was crying out in pain and the meds available were not working would you really care what it costs to transport them back to the hospital to get the pain under control?  Some also make assumptions that hospice and nursing homes are only for the very old who probably need to die but that is simply not true. *Nor should you make assumptions that a facility can provide everything needed with just a doctor's order.*  Check your own state and see how many different levels of facilities there are and what can or can not be done in each.   A Paramedic is also very limited and might only be able to do something for the short term but chances are the medications they carry are the same as the nursing home with the same limitations. *This is why transport might be required* rather than leaving a patient to suffer and not get the opportunity to be placed in a facility which can provide a higher level of comfort.



All of which is why I qualified my statements by saying this:



> Now if there is intractable pain or something that isn't being effectively managed, then that's different.



Obviously if the patient isn't getting the care they need, then they require transport to a different facility. 

The overall point, however, was that if the dying person doesn't want hospital treatment, and the only reason EMS was called is because the family or staff of the dying patient "freaked out", then that is inappropriate. Understandable perhaps, but still inappropriate.

I love how you so frequently accuse others of "making assumptions", at the same time having speculated yourself that the person you are responding to has little or no experience with the topic being discussed.


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## Clipper1 (Dec 6, 2013)

Halothane said:


> The overall point, however, was that if the dying person doesn't want hospital treatment, and the only reason EMS was called is because the family or *staff of the dying patient "freaked out", then that is inappropriate*. Understandable perhaps, but still inappropriate.



Freaked out? What if it was your wife or child? What you might consider freaked out might just be concern or fatigue from watching a loved one die. You again are forming an opinion (and your personal opinion) from just a few minutes and not weeks or even a full shift of observing.   The same goes for "staff freaking out". You are not there for 12 hours for several days.  Many patients on comfort care can not carry on a normal conversation.   Some patients are also "directed" as "what is best" by a family member or a doctor who just wants the patient out of the hospital and maybe even out of his care. Some of these patients are young women with breast cancer who wanted to continue the fight but were told by their insurance or doctor the next level would be too expensive. Since cost is one of your concerns you would probably understand it is best to just hope a patient dies before running up anymore cost. And then some patients are just dumps into a facility because of bed space and an easy way out of the cost thing. But, at some nursing homes there are actually patient advocates who fight to get a patient placed more appropriately and with a few calls to doctors and SWs or CMs, the patient is sent back to be placed more appropriately or put on hospice care inside the hospital.

Don't assume all family members or staff just freak out for no reason or that transport of comfort care patients to a facility which can actually provide a higher level of comfort as inappropriate. There is a lot you need to learn about the US health care system. There are resources on line which explains the level of care by facilities and hospice also has some great articles on how to use hospice and the limitations for use of hospice or just why some don't get the hospice care they need.  You will then see why some of your comments are incorrect.


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## Carlos Danger (Dec 6, 2013)

Clipper1 said:


> Freaked out? What if it was your wife or child? What you might consider freaked out might just be concern or fatigue from watching a loved one die. You again are forming an opinion (and your personal opinion) from just a few minutes and not weeks or even a full shift of observing.   The same goes for "staff freaking out". You are not there for 12 hours for several days.  Many patients on comfort care can not carry on a normal conversation.   Some patients are also "directed" as "what is best" by a family member or a doctor who just wants the patient out of the hospital and maybe even out of his care. Some of these patients are young women with breast cancer who wanted to continue the fight but were told by their insurance or doctor the next level would be too expensive. Since cost is one of your concerns you would probably understand it is best to just hope a patient dies before running up anymore cost. And then some patients are just dumps into a facility because of bed space and an easy way out of the cost thing. But, at some nursing homes there are actually patient advocates who fight to get a patient placed more appropriately and with a few calls to doctors and SWs or CMs, the patient is sent back to be placed more appropriately or put on hospice care inside the hospital.
> 
> Don't assume all family members or staff just freak out for no reason or that transport of comfort care patients to a facility which can actually provide a higher level of comfort as inappropriate. There is a lot you need to learn about the US health care system. There are resources on line which explains the level of care by facilities and hospice also has some great articles on how to use hospice and the limitations for use of hospice or just why some don't get the hospice care they need.  You will then see why some of your comments are incorrect.



Ahhh, OK.......


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## triemal04 (Dec 6, 2013)

Rialaigh said:


> Stop treating patients that DON'T want to be treated....there are way more of them out there than you would think...





Chase said:


> Then they should have never called EMS.





Halothane said:


> If you don't want your car towed to an auto mechanic, you don't call a tow truck. If you don't want to be treated at a hospital, you don't call EMS. Pretty simple.





triemal04 said:


> Many people call because they aren't sure of what to do, are panicking, don't know what the actual patient wants, or because they are required to (for someone living in an assisted-living center for instance).  While the actual patient may not want care, (or even need care in some cases) the simple fact that 911 was called does not in any way, shape, or form mean that they have consented to treatement.  Rialagh is very right; we need to stop treating people who don't want treatement.


I'm not going to repeat myself to much.  We often get called to see people that do not WANT, or NEED our help.  The simple fact that 911 was called or that we show up does not change this.


Halothane said:


> So what is this magical "comfort care" that you can provide, that the nursing home staff and palliative care team cannot?


Generally it's pain management.  If the patient is in pain due to their chronic condition or a NEW problem that is presenting itself, we can, and should treat that as appropriate.  It does not matter if the patient is in a nursing home; many, including skilled nursing homes, do not have the capabilities or drive to provide pain management beyond the patient's already prescribed regime.  Hospice is different, but it still requires the hospice nurse to BE THERE, and potentially to have to stop at a pharmacy to get the needed medications.  We very well may be the more appropriate initial response.  


Halothane said:


> Any patient that has been made "comfort care" is already being managed by a hospice or palliative care team. This patient in question was already in a nursing facility and already has orders and is already being managed by a physician. They should be able provide for his comfort needs.


I'm sorry, but you people are living in a fantasy land.  For many, many parts of the country a DNR with built in advance directives (POLST is one common name for it) is quite common, and getting even more common as time goes on.  A "DNR with comfort measures" IS NOT something that only is given to people who are very near death as you and chase seem to believe.  It IS NOT only given to patient's who are under hospice care or live in a skilled nursing facility; many people have it that lead very normal and healthy lives because...they are quite healthy.

If this trend towards making a determination about what type of invasive and longterm care is wanted before it is actually needed continues, you all need to wrap your heads around the fact that there are people who will want to die naturally and peacefully whenever it may happen, and they will make this determination before they ever become ill.


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## Carlos Danger (Dec 6, 2013)

triemal04 said:


> A "DNR with comfort measures" IS NOT something that only is given to people who are very near death as you and chase seem to believe.  It IS NOT only given to patient's who are under hospice care or live in a skilled nursing facility; many people have it that lead very normal and healthy lives because...they are quite healthy.
> 
> If this trend towards making a determination about what type of invasive and longterm care is wanted before it is actually needed continues, *you all need to wrap your heads around the fact that there are people who will want to die naturally and peacefully whenever it may happen, and they will make this determination before they ever become ill.*



I completely understand that, in fact that is my WHOLE POINT, and I'm pretty sure at least part of what Chase was getting at, too. 

Not sure exactly what your experience is or where the disconnect is here, except that you and Clipper seem to be looking so hard for opportunities to point out that others "need to learn about the healthcare system" and "need to wrap your heads around things", that you think you see them when they aren't there.


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## triemal04 (Dec 6, 2013)

Halothane said:


> I completely understand that, in fact that is my WHOLE POINT, and I'm pretty sure at least part of what Chases was getting at, too.
> 
> Not sure where the disconnect is here, except that you and Clipper seem to be looking so hard for opportunities to point out that others "need to learn about the healthcare system", that you think you see them when they aren't there.


No, I highly doubt that was the point of what he was getting at.  And if that is your point, your comments make that exceeding hard to see.  


Chase said:


> If the patient and/or patient's family truly does not want treatment as in "Comfort Measures Only" then they should not be calling EMS and certainly not be transporting to the hospital.* Most of these type of patients have home health and hospice care.*





Chase said:


> *I have never seen a single patient come in with a "Comfort Measures Only" DNR that was leading anything close to a "normal life"..*





Halothane said:


> *Any patient that has been made "comfort care" is already being managed by a hospice or palliative care team.*


You don't get it both ways.

Both of you are wrong.  It's as simple as that.  Learn from it, and move on.


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## Carlos Danger (Dec 6, 2013)

Both ways?

I stated that when an individual has decided they'd rather die at home than be taken to a hospital, then their caretakers should respect that and not call EMS when their condition worsens. 

That is essentially the same thing YOU wrote, AFTER telling Chase that he was wrong for saying it.

So one of us is trying to have it both ways, but it isn't me.


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## triemal04 (Dec 6, 2013)

Once again.  This:





Halothane said:


> Any patient that has been made "comfort care" is already being managed by a hospice or palliative care team.


  is completely, and utterly, WRONG.

Both of you have said essentially the same thing, and ARE  WRONG.  A *"DNR with comfort measures only"* is not something that is only given to people on hospice, and who are managed by in-home healthcare.  In many parts of the country it is a very common thing, and many of the people who hold one live independantly with no need of hospice, or any type of home care.

Do you understand that, or not?

edit:  It is very common to see patient's who, due to a sudden, potentially life ending event, are no longer capable of explaining what they want, and do not have a group of medical providers who deal daily with them present because they never had need for such.  At that point, their POLST is very important, and people in EMS may be the first people (aside from the patient's primary care physician) to see it.  You both seem to think that only people who were already ill or otherwise close to dying will have one; that is not true.  Normal people often have a DNR/POLST/whatever in place.  EMS needs to be aware of that, and understand that they will need to follow it, even if up until that moment the patient had been quite healthy.


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## Carlos Danger (Dec 6, 2013)

triemal04 said:


> Both of you have said essentially the same thing, and ARE  WRONG.  A *"DNR with comfort measures only"* is not something that is only given to people on hospice, and who are managed by in-home healthcare.  In many parts of the country it is a very common thing, and many of the people who hold one live independantly with no need of hospice, or any type of home care.
> 
> Do you understand that, or not?



I never said or even implied that everyone with a DNR is in hospice or receiving home healthcare. You completely fabricated that. The term "DNR", doesn't even appear in any of my posts, so I don't know where you even got that from.

It sounds like you have some terms confused. "Comfort care" is a totally different thing from a DNR. A DNR is an advanced directive that comes from the patient. "Comfort care" is a management strategy for nursing staff and caregivers that generally requires a physician's order. Usually these patients have palliative care consulted and are referred to hospice where they are managed at home or in a facility. Specific circumstances vary, of course, as does terminology.

The bottom line is that any patient has the right to do whatever they want. Stay home, go to the hospital, enter hospice, don't enter hospice, whatever. *My point was that a patient at the end of their life shouldn't be stuffed into an ambulance and taken to the hospital just because their condition worsens, when they've made it clear that they'd rather stay home. That is all. *

I don't understand why you think people who'd rather stay home should be forced to go to the hospital. You should perhaps spend some time reading about advanced directive and the concept of self-determination.


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## triemal04 (Dec 6, 2013)

Halothane said:


> I never said or even implied that everyone with a DNR is in hospice or receiving home healthcare. You completely fabricated that. The term "DNR", doesn't even appear in any of my posts, so I don't know where you even got that from.
> Perhaps because everything said has been about a "DNR with comfort measures only" or "comfort measures DNR."
> 
> It sounds like you have some terms confused. "Comfort care" is a totally different thing from a DNR. A DNR is an advanced directive that comes from the patient. "Comfort care" is a management strategy for nursing staff and caregivers that generally requires a physician's order. Usually these patients have palliative care consulted and are referred to hospice where they are managed at home or in a facility. Specific circumstances vary, of course, as does terminology.
> ...





Halothane said:


> If you don't want your car towed to an auto mechanic, you don't call a tow truck. If you don't want to be treated at a hospital, you don't call EMS. Pretty simple.


I would very much like to hear your explanation for saying this.  As I said twice, 911 may be called in error for many reasons, and the simple fact that 911 was called does not mean that the actual patient needs, or wants our help.  Here you would seem to be saying the opposite.  

Explain yourself.


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## VFlutter (Dec 6, 2013)

triemal04 said:


> Both of you are wrong.  It's as simple as that.  Learn from it, and move on.



That is a bold statement to make. Let's agree to disagree. I will respond further when I get off work.

Ironically, I just got done making a patient comfort measures only. If they do leave the hospital the expectation is that they will not return.


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## Clipper1 (Dec 6, 2013)

triemal04 said:


> I would very much like to hear your explanation for saying this.  As I said twice, 911 may be called in error for many reasons, and the simple fact that 911 was called does not mean that the actual patient needs, or wants our help.  Here you would seem to be saying the opposite.
> 
> Explain yourself.
> 
> ...



Comfort Care, Advanced Directives, DNR and DNI are all very different terms with very different treatment plans.   


Comfort Care is defined in EVERY state (all 50) in the United States because of CMS and reimbursement.  This includes Washington as well as Oregon, California, Montana etc.  This does not mean every facility is equal unless they have some level of providing hospice services if the patient meets the qualifications.  The qualifications are determined by a physician and maybe the Ethics committee by the legal guidelines of that state. CMS is involved because of reimbursement and acceptance into a facility or service.  It is not up to the Paramedic to decide a patient should be a DNR or in Comfort Care and make this so by just calling the family.


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## Clipper1 (Dec 6, 2013)

Halothane said:


> Both ways?
> 
> I stated that when an individual has decided they'd rather die at home than be taken to a hospital, then their caretakers should respect that and not call EMS when their condition worsens.
> 
> ...



Chase and I also agreed about reasons for a patient who is in comfort care to be brought to the hospital. Example: If their PICC or indwelling port (special "IVs") is not functioning, they will not be able to receive the comfort meds.  For this EMS should transport. I guess the family could try to get a patient this brittle into their POV.  Dying in comfort is the objective here.  

Until you have actually worked with these patients for longer than the few minutes you spend on scene, you might not be able to appreciate their suffering and why dying in a hospital where a palliative care RN and Physician can assess them several times during a day as they adjust the meds is sometimes the better option. No one has a crystal ball to see in the future as to how much a patient will suffer as they die and there are limits to just killing the patient by OD'ing them on the home pain medications. When one of these patients is admitted, the physician or Palliative NP will assess and maybe switch meds to one which is done in a hospital rather than giving this responsibility to the family at home.


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## triemal04 (Dec 6, 2013)

Chase said:


> That is a bold statement to make. Let's agree to disagree. I will respond further when I get off work.
> 
> Ironically, I just got done making a patient comfort measures only. If they do leave the hospital the expectation is that they will not return.


Please do.  It may be enlightening, and I'll even promise to take a deep breath before I respond.

I don't think that you or Halothane understand how prevalent standardized forms for advance directives are becoming nationwide, who uses them, or what they actually mean.

In all the forms that I linked to in another thread (and all the ones that I didn't but can be found through the POLST website) one option is for a person to declare themself a "DNR with comfort measures only."  Which means that they don't want life sustaining treatement.  I think that you will agree that is what it means.

It does not neccasarily mean that the person is in the final stages of their life; it just means that should something happen they do not want life sustaining treatement and want to die naturally; hence why otherwise very healthy people will choose that option.

It doesn't mean that they will stop taking any medications that they are currently on, or that they can't choose to temporarily or permanently rescind it and start new treatements (such as for a UTI as was mentioned earlier).

What it means is that if that person becomes incapacitated their wishes for their treatement are known, and will be followed.

So there are situations where someone who is a "DNR with comfort measures only" will call 911 and WANT to be treated, as is their right.  

There are situations where someone who is a "DNR with comfort measures only" will call and the needed treatement is something perfectly in line with their wishes.

There are situations where someone else will call 911 for the reasons I gave several times and the patient WILL NOT want to be treated, as is their right.

Is this getting clearer?


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## Carlos Danger (Dec 6, 2013)

triemal04 said:


> Please do.  It may be enlightening, and I'll even promise to take a deep breath before I respond.
> 
> I don't think that you or Halothane understand how prevalent standardized forms for advance directives are becoming nationwide, who uses them, or what they actually mean.
> 
> Is this getting clearer?



Look man, I don't even know what you are talking about anymore. You are just rambling and repeating yourself and making baseless accusations about others not knowing what they are talking about. I really don't even see where you've contradicted anything I wrote. 

Why not just drop it and have a beer or two before you give yourself a stroke.


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## chaz90 (Dec 6, 2013)

I've been trying to follow along in this thread, but I'm afraid I've lost all sense of what's going on in every direction.


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## triemal04 (Dec 6, 2013)

Halothane said:


> If you don't want your car towed to an auto mechanic, you don't call a tow truck. If you don't want to be treated at a hospital, you don't call EMS. Pretty simple.


I would very much like to hear your explanation for saying this. As I said twice, 911 may be called in error for many reasons, and the simple fact that 911 was called does not mean that the actual patient needs, or wants our help. Here you would seem to be saying the opposite. 

Until you can explain why you said that I've got nothing else to say to you.

edit:  I'm also still waiting for you to point out where I've said that a patient should be forced to go to the hospital, as you accused me of saying in your last post.


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## Rialaigh (Dec 7, 2013)

Here it is. 

This is not black and white.

 This is not a yes or no thing

 You, as a medical provider have to make a judgement call on what you think the patients wishes are. If I show up on scene with an unresponsive patient, and family is on scene, and I have reason to believe the family knows what this patient would want done in this situation, then I am going to do what the family wants, if that's no interventions at all other than a bit of O2 and a ride to the hospital that is fine with me.

 I am not legally, morally, or ethically obligated to treat a patient to the fullest extent that I can, If I have the belief that the patients wishes would not have me treat them to the fullest extent. Those can be verbally expressed by the patient, or through a patient advocate that I believe is reputable (such as a family member). 


Everyone always talks about expressed consent to treat, that does not mean we can treat the patient to the fullest extent if they are altered or unresponsive. It simply gives us the power to treat the patient as we think *they would want to be treated *in these situations.


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## Handsome Robb (Dec 7, 2013)

Rialaigh said:


> Here it is.
> 
> This is not black and white.
> 
> ...



I believe you're looking for implied consent in the instance of an altered or unresponsive patient.


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## Rialaigh (Dec 7, 2013)

Robb said:


> I believe you're looking for implied consent in the instance of an altered or unresponsive patient.



Yes thank you, total brain fart at that time of night


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