# Code 2 with hospice and dnr orders



## smhee (May 2, 2014)

Say you are doing code 2 to a patient's home from a hospital on hospice order and has a valid dnr, say he dies enroute where do you take him? Do we take a dead body to the hospital or do we pull over wait for coroner to pronounce time of death or ask family what they want us to do weather it be take him to a morg or take him home still? I asked a couple pple from my company and most don't have any idea and one who is wrong with everything we talk about said take him to a hospital...but do we take dead body's to the hospital? I thought in school (which was 4 years ago) they said not to take a dead body to the hospital because there is no point....idk something thats bothered me


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## TransportJockey (May 2, 2014)

What is code 2? Here thats lights with no siren, which is illegal.  
As for you question, take them to your destination, whether it be their home or inpatient hospice. And inform the hospice nurse that is there to meet you.


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## Wolfe (May 2, 2014)

This happened to me not too long ago, I had heard different opinions when discussing this possible scenario (earlier, not during this call) so I chose to have our shift supervisor make the decision on whether or not to send an ALS truck/medic to field pronounce or redirect to sending hospital.  I was sent back to the sending hospital to have the patient pronounced.

I was told to *never* deliver a dead patient to their/families home in my system.  We either have a medic/ALS sent or redirect for an ER to pronounce.

In my system Code 2 is NO lights/NO sirens, Code 3 is lights/sirens.


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## rmabrey (May 2, 2014)

Never pull over and pronounce. Your truck is now a crime seen. 

Answers vary on this based on where you are going.  If the patient is being transferred home, take them to the hospital.  If they are going to a hospice center,  taken them there.


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## Medic Tim (May 2, 2014)

Your company should have a policy that covers this...


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## smhee (May 2, 2014)

Lol you would think we would medic tim....they might but they just don't tell pple it, I work very early shifts or at a place where there are no supervisors only dispatch so I asked dispatch and they said "ummmm that's a good question" and where im at (laco) code 2 is no lights/no siren and hey if my rig is a crime scene means easy day for us?? Lol jk we don't come into these calls very often and when we do get them the patient dies b4 our crew even gets to the hospital for tx and a family member was following us on the fwy the entire time so shouldn't I have atleast stopped and told him what's going on then tx to hospital going off of what wolfe said?


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## chaz90 (May 2, 2014)

Perhaps call/email one of your supervisors and ask? This really is something that will vary by policy and area.


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## smhee (May 2, 2014)

Yeah I need to just been forgetting while it's on my mind


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## Wolfe (May 2, 2014)

That is pretty much what happened on my call, we were transporting the patient with patient's daughter following behind.  Patient was belly breathing and I witnessed his last breath about 5 minutes after my last set of vitals, checked for pulse and breath sounds.  I had my partner pull over to check again without road noise and bumps to be sure before calling our supervisor.  The patient's daughter pulls in behind us and comes to the side door where my partner was standing to see if I needed any assistance.  I told her we would be returning him to the hospital.  I did *not* tell her that he had expired/passed/died, I believe that is up to the person who pronounces death.


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## Christopher (May 2, 2014)

Wolfe said:


> I told her we would be returning him to the hospital. I did *not* tell her that he had expired/passed/died, I believe that is up to the person who pronounces death.



If you're not resuscitating the patient...guess what: *you've *pronounced them dead.

Please don't parrot silly EMS phrases like "we don't pronounce people dead."



rmabrey said:


> Never pull over and pronounce. Your truck is now a crime seen.
> 
> Answers vary on this based on where you are going.  If the patient is being transferred home, take them to the hospital.  If they are going to a hospice center,  taken them there.



We pronounce and take folks to the morgue all the time. Sometimes while they're in our truck.

Doesn't make it a crime scene.


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## BASICallyEMT (May 2, 2014)

*Base Hospital*

Stay enroute to destination and contact Base Hospital?


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## Christopher (May 2, 2014)

smhee said:


> Say you are doing code 2 to a patient's home from a hospital on hospice order and has a valid dnr, say he dies enroute where do you take him? Do we take a dead body to the hospital or do we pull over wait for coroner to pronounce time of death or ask family what they want us to do weather it be take him to a morg or take him home still? I asked a couple pple from my company and most don't have any idea and one who is wrong with everything we talk about said take him to a hospital...but do we take dead body's to the hospital? I thought in school (which was 4 years ago) they said not to take a dead body to the hospital because there is no point....idk something thats bothered me



Call a supervisor, find out what they'd like to do. My system would probably have us continue to the home, rendezvous with the funeral home service of their choice (hospice likely obviates an autopsy), and transfer the body there.

Why? This is the right thing to do. The patient obviously expressed a wish to die in their home.

Many times I've sat with a stretcher in a living room, the deceased on it, waiting on a funeral transport. We wait on the family, call around for the family to see who else should come by, and try and get the ball rolling on their needs in the interim.


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## TransportJockey (May 2, 2014)

It not only will vary area to area, it might vary hospice company to hospice company.


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## rmabrey (May 2, 2014)

Christopher said:


> We pronounce and take folks to the morgue all the time. Sometimes while they're in our truck.
> 
> Doesn't make it a crime scene.



I should have said this varies area to area. It is a crime scene here.


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## Christopher (May 2, 2014)

rmabrey said:


> I should have said this varies area to area. It is a crime scene here.



I mean, I live in backwater, backwoods, mom's your sister North Carolina and that's not the case here. I mean, we legislate away rights for entire classes of citizens like its the 1800's and just because somebody died doesn't automagically make whatever they were touching last a crime scene. You don't even have to take math every year in high school here...(ok I've made my point, we're D.U.M. dum yet have sensible laws on this)

You should find out whether or not that's just some line somebody likes reciting or the actual truth.


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## mycrofft (May 2, 2014)

CODE 2: "Go fast and when you get in trouble we deny we told you to".

Or "Don't stop for pizza".

Follow your protocols. Don't ask ppl, ask the boss and read the protocol. If I had a doubt, I'd either pull over and call 911 for a cop, or if it was a couple blocks, finish the run and act amazed.


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## mycrofft (May 2, 2014)

smhee said:


> Lol you would think we would medic tim....they might but they just don't tell pple it, I work very early shifts or at a place where there are no supervisors only dispatch so I asked dispatch and they said "ummmm that's a good question" and where im at (laco) code 2 is no lights/no siren and hey if my rig is a crime scene means easy day for us?? Lol jk we don't come into these calls very often and when we do get them the patient dies b4 our crew even gets to the hospital for tx and a family member was following us on the fwy the entire time so shouldn't I have atleast stopped and told him what's going on then tx to hospital going off of what wolfe said?



Oh, there are supervisors, but they may be asleep. One sign you need to keep your eyes open for another company, or at least a day shift.


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## Medic Tim (May 2, 2014)

rmabrey said:


> I should have said this varies area to area. It is a crime scene here.




Even with a DNR hospice pt? Of so that's ridiculous.


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## mycrofft (May 2, 2014)

I don't know if being in an ambulance keeps it from being an "unaccompanied death", but it might not…not a crime, but a classic basis for coroner's intervention.


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## rmabrey (May 2, 2014)

mycrofft said:


> I don't know if being in an ambulance keeps it from being an "unaccompanied death", but it might not…not a crime, but a classic basis for coroner's intervention.



This is probably a better way to phrase it. We have to sit and wait on the coroner. They still consider it a "crime scene", despite the lack of an actual Investigation


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## mycrofft (May 2, 2014)

*"Unaccompanied death" is not a crime.*

Not a crime scene (someone dying does not a crime scene make), but they have to bring their "pushed, jumped or fell" card and fill it out.

A crime scene gets real tense for you real quick. A simple cause of death initial look-around is not so much.


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## JPINFV (May 2, 2014)

mycrofft said:


> I don't know if being in an ambulance keeps it from being an "unaccompanied death", but it might not…not a crime, but a classic basis for coroner's intervention.




Depends. In California, it's a corner's case if it occurs after 20 days of seeing a physician. Considering that this is a hospital to home transport, that criteria shouldn't apply. Considering that it's a hospice case, the rest of the criteria most likely does not apply. 

http://www.co.merced.ca.us/documents/Sheriff%27s%20Department/Frequently%20Asked%20Questions.PDF

http://www.leginfo.ca.gov/cgi-bin/displaycode?section=gov&group=27001-28000&file=27490-27512


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## vcuemt (Jun 5, 2014)

Christopher said:


> If you're not resuscitating the patient...guess what: *you've *pronounced them dead.
> 
> Please don't parrot silly EMS phrases like "we don't pronounce people dead."



Surely you realize the legality of pronouncing someone dead vs. deciding they aren't coming back? Or maybe EMS is done different one state to the south.


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## Christopher (Jun 5, 2014)

vcuemt said:


> Surely you realize the legality of pronouncing someone dead vs. deciding they aren't coming back? Or maybe EMS is done different one state to the south.



I must make a diagnosis of 'death', 'dead', 'died', 'ceased to be', 'is no more' in order to decide to not resuscitate the patient.

I don't sign their death certificate, but I've certainly "pronounced" them dead.

I'm reminded of the hordes who believe we can't/don't/aren't/isn't/willn't/wouldn't/shouldn't diagnose...


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## vcuemt (Jun 5, 2014)

Christopher said:


> I must make a diagnosis of 'death', 'dead', 'died', 'ceased to be', 'is no more' in order to decide to not resuscitate the patient.
> 
> I don't sign their death certificate, but I've certainly "pronounced" them dead.
> 
> I'm reminded of the hordes who believe we can't/don't/aren't/isn't/willn't/wouldn't/shouldn't diagnose...



Perhaps that's what you do. I follow my protocol when deciding whether or not to begin resuscitation. No diagnosis necessary.


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## Akulahawk (Jun 5, 2014)

I generally follow protocol on this stuff. Usually the protocol is that I can transport the now deceased patient to the mortuary of their choice (if known) or I return to the point of origin. This is, of course, only when dealing specifically with hospice/DNR patients. Otherwise I'm working to either prevent the code or I'm working the code... 

In any event, I must first determine that the patient is now "absent vital signs." While I don't "diagnose" death, and am not the person that signs that death certificate, my findings will certainly make it clear that I've determined that the patient is, in fact, dead and no longer needs services... 

Yes, we diagnose all the time, within the limits of our education, experience and law/regulation. What we're not doing is making _medical_ diagnoses. That's for physicians. Nurses make Nursing Diagnoses. Paramedics make Field Diagnoses. We all diagnose so that we can develop a plan to provide care for our patients. If we don't diagnose and treat symptomatically, then we're doing nothing more than responding to stimuli. See x, do y...


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## Christopher (Jun 5, 2014)

vcuemt said:


> Perhaps that's what you do. I follow my protocol when deciding whether or not to begin resuscitation. No diagnosis necessary.



(please read 'you' to be the Royal You/plural you/y'all you, not 'you' you)

Protocols are simply guidelines that set the floor, not the ceiling, of your care. They cannot possibly replace sound clinical judgement, and when used they should only supplement it. You should be willing to stand behind your diagnosis/pronouncement of death without relying solely on protocol.

My problem with this whole thread is not the act of pronouncing somebody dead, which people are scared of it seems, but that somebody wasn't willing to use the word "dead" with a patient's family.

They hid behind "pronounce" being some special fantasy legal word reserved for magical fairy medical examiners in white vaulted towers (with rainbows 'n stuff; void where prohibited by law; remember you will go to jail if you say it aloud).

If you're not willing to confidently say, "they're dead, and I pronounced them dead", then you'd better be doing full resuscitation.



Akulahawk said:


> Paramedics make Field Diagnoses



Dodging that one, so I'm sorry I opened this can of worms...language is also a tricky subject in EMS apparently.


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## gonefishing (Jun 7, 2014)

Been there done that in LACO.  If DNR going to hospice center, continue on.  Inform staff before removal of body off unit.  If they accept, GREAT! if not such as in my case you roll out an ALS truck pronounce and roll back to facility you took out of due to most likely your MAR thats up the street will not want the body.


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## Brandon O (Jun 7, 2014)

Legal issues aside, if you're not attempting resuscitation you'd better have made the decision they're dead, otherwise you're the one who killed them <_<


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## usalsfyre (Jun 9, 2014)

vcuemt said:


> Perhaps that's what you do. I follow my protocol when deciding whether or not to begin resuscitation. No diagnosis necessary.


"At no point in your rambling, incoherent response were you even close to anything that could be considered a rational thought. Everyone in this room is now dumber for having listened to it. I award you no points, and may God have mercy on your soul."


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## eastman (Jun 13, 2014)

why are you even transporting a hospice patient with a dnr?


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## NomadicMedic (Jun 13, 2014)

eastman said:


> why are you even transporting a hospice patient with a dnr?




Because DNR doesn't mean "do not treat". A hospice patient may have something simple, like an easily treatable UTI. Would you not treat that patient?


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## eastman (Jun 13, 2014)

Misread the post, thought theoretical patient was being worked against dnr


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