# Pediatric Arrest: parents wishes



## RICollegeEMT (Nov 8, 2016)

Hyperthetical situation:

You're at post in a park, nearby is a kid playing on a playground.  Appears to be elementary school age.  Suddenly he collapses. You run (ok ok scene safety so you fast walk) over, seeing no safety issues you go to the kids side. You notice he's not breathing and no palpable pulse.  

Witnessed cardiac arrest.  

You tell your partner to grab the equipment and are about to perform CPR when the person identifying themselves as his mother tells you to stop. That she does not want the kid worked.    

She has no formal DNR paperwork just that it's against her wishes.  Despite pleading with her she does not change her mind. 

For senario sake we will say this park has no cell or radio service and you forgot your carrier pigeon so Med Control is unreachable.  And we will say nobody else is in the park, just your unit and the mother with child. 


How do you proceed?

I know I threw in a lot of "snags" but I wanted to boil it down to the core issue at hand.


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## Summit (Nov 8, 2016)

I don't think I'd have time to verify mom's identity and parental authority in the midst of coding a ped.

Turns out she is a stranger suffering delusional psychosis? Well you cannot take back terminating resuscitation. I'd have an easier time defending continuing under compiled consent in the face of unclear but opposing parental override in a life threatening situation.

The decision is consequential, dire, and temporally critical. This isn't mom saying "no I don't want an ambulance bill for a broken wrist I'll drive my kid in myself."

Is this a super contrived scenario or did this actually happen?


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## EpiEMS (Nov 8, 2016)

RICollegeEMT said:


> Hyperthetical situation:
> 
> You're at post in a park, nearby is a kid playing on a playground.  Appears to be elementary school age.  Suddenly he collapses. You run (ok ok scene safety so you fast walk) over, seeing no safety issues you go to the kids side. You notice he's not breathing and no palpable pulse.
> 
> ...



Assuming I'm a BLS unit...
To the partner: "Start CPR, I'll start ALS for a cardiac arrest, and PD/Fire for manpower."

To the purported mother: "Ma'am, your child is not breathing and [his/her] heart isn't beating. We need to help [him/her]. Unless you can provide me [a complete DNR/MOLST or if the child has a DNR bracelet -- this all depends on the state I'm in], I have a legal obligation to help this child to the best of my ability until advised otherwise by a higher medical authority."

After all:










RICollegeEMT said:


> She has no formal DNR paperwork just that it's against her wishes.  Despite pleading with her she does not change her mind.



"Ma'am, in the absence of a valid order from a higher medical authority or a valid [DNR/MOLST/etc.], I have a legal, ethical, and professional obligation to perform any and all life sustaining measures that are authorized by my protocols."

Keep performing CPR, and apply AED per protocol. Keep trying to reach ALS.



RICollegeEMT said:


> For senario sake we will say this park has no cell or radio service and you forgot your carrier pigeon so Med Control is unreachable.  And we will say nobody else is in the park, just your unit and the mother with child.



So this is a bit unrealistic, and I'm not sure how to proceed. I have no protocols for BLS termination of pediatric resuscitation, and I can't ethically *cease* until it's clearly futile, so I'd probably err on the side of working it until I can get ALS on scene or medical direction on the line.



RICollegeEMT said:


> How do you proceed?
> 
> I know I threw in a lot of "snags" but I wanted to boil it down to the core issue at hand.



To me, the core issue is: Do we disregard a (purported) parent's wishes in the case of a life-threatening emergency involving a minor?

The answer is a two part-er.

1) I cannot verify the parent's status. However, people don't generally claim to be parents in a resuscitation situation like this - *reasonably*, I can assume they are the parent.
2) Ethically, I have an obligation to treat a child in extremis, unless there is a clear contravening reason to do so (i.e. a terminal condition and there's a documented advanced directive of some kind in place). Can I do it against the parent's wishes? Yes, when I believe it against the best interests of the child. Firstly, I doubt I'd be sanctioned, and secondly, even if I were sanctioned, I would rather give this child a chance.


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## Midazzled (Nov 8, 2016)

I would work him. With no paper in hand, you have a pretty clear duty to provide care. Does mom become a threat to your safety or some other thing I'm not seeing?


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## RICollegeEMT (Nov 8, 2016)

My line of thinking is what you guys are saying.  And purely hypothetical.   

I figure it's better to be sanctioned for working the kid than to be sanctioned for not working them. 

I just wanted to see if my rational was "appropriate" or not.


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## EpiEMS (Nov 8, 2016)

RICollegeEMT said:


> My line of thinking is what you guys are saying.  And purely hypothetical.
> 
> I figure it's better to be sanctioned for working the kid than to be sanctioned for not working them.
> 
> I just wanted to see if my rational was "appropriate" or not.



I'd wager that you would not get sanctioned in the former, but would be in the latter. I'd like to hear several lawyers' answers, though.


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## Carlos Danger (Nov 8, 2016)

Work it, ask forgiveness later.


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## NysEms2117 (Nov 8, 2016)

Remi said:


> Work it, ask forgiveness later.


This x100. Sorry mom either give me cold hearted paperwork showing this is your child, and he/ she had legal documents(DNAR), or I'm going to do my job. Yell at me later if you must


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## Gurby (Nov 8, 2016)

RICollegeEMT said:


> For senario sake we will say this park has no cell or radio service and you forgot your carrier pigeon so Med Control is unreachable.  And we will say nobody else is in the park, just your unit and the mother with child.



Even if medical control was available, you still need to initiate CPR immediately and call them later once you get the chance.


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## VentMonkey (Nov 8, 2016)

RICollegeEMT said:


> How do you proceed?







He says "it's cool".

But seriously, you proceed like any other arrest. If "parent" is in hysterics (hard to believe she has no proof she's in fact mom), and adamant about her "wishes", call rampart whilst initiating non invasive therapies, i.e., BLS CPR til y'all hash it out. Done, and done.


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## ERDoc (Nov 8, 2016)

As the person taking the call in medical control, I would tell you to work it and let the hospital sort out the details.  Too many unknowns in this situation.  Reality will be just the opposite.  Parents want anything and everything done for their kids, even if it isn't indicated or helpful.  You will be more likely to come across a scene where the parent wants you to do CPR even though the child is long dead.


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## Handsome Robb (Nov 8, 2016)

ERDoc said:


> As the person taking the call in medical control, I would tell you to work it and let the hospital sort out the details.  Too many unknowns in this situation.  Reality will be just the opposite.  Parents want anything and everything done for their kids, even if it isn't indicated or helpful.  You will be more likely to come across a scene where the parent wants you to do CPR even though the child is long dead.



I was waiting for a Doc to weigh in on this. 

No physician is going to tell you to not work this kid. 

I've got orders to not work a pedi once, and she was on hospice secondary to cancer but the DNR hadn't been signed yet and even that was a 10 minute long phone conversation. 

Like others said, you need to work this patient. No jury of your peers is going to convict you of anything for trying to save a child if it ever even made it to that point. 


Sent from my iPhone using Tapatalk


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## ERDoc (Nov 8, 2016)

> "Handsome Robb, post: 625159, member: 9927"No jury of your peers is going to convict you of anything for trying to save a child if it ever even made it to that point.
> Sent from my iPhone using Tapatalk



Don't trust this too much.  You will never be judged by a jury of your peers.  You will be judged by a jury of non-medical people too stupid to get out of jury duty.  Practice accordingly.


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## VentMonkey (Nov 8, 2016)

ERDoc said:


> Don't trust this too much.  You will never be judged by a jury of your peers.  You will be judged by a jury of non-medical people too stupid to get out of jury duty.  Practice accordingly.


"When in doubt, base it out." 

Pretty much what the good Doc is saying. In theory even a jury of non-medical lay people would be hard pressed to have the prosecution overturn a practicing EM physicians words so long as you did your part, they'll have done theirs, and protocols are never more pertinent than this scenario here.

The moral of the stort here, op: don't over think it, even field _good _field clinicians know when they're limits are exceeded, this would be a prime example.


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## Handsome Robb (Nov 8, 2016)

ERDoc said:


> Don't trust this too much.  You will never be judged by a jury of your peers.  You will be judged by a jury of non-medical people too stupid to get out of jury duty.  Practice accordingly.



While I agree I'd find it hard to believe a group of idiots incapable of getting out of jury duty would convict someone in this case either. 

With that sound, definitely sound advice. 


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## Clare (Nov 9, 2016)

Ambulance personnel are obligated to do what is in the best interest of the patient, *and *if the patient is a child that must be in-line with the wishes of the parents.  The exception to this being if a court orders treatment against the parent's wishes.  This has been very rare and usually happens in the setting of chemotherapy for cancer.  There have been two or three cases nationally where this has happened now in the interests of "providing the necessities of life"; interestingly one was a case vs Auckland DHB for a patient who was ventilated in ICU.  The judge ruled a ventilator was not a "necessity of life" and it could be withdrawn.

There is no legal requirement to view a DNR or AND request.  It is perfectly acceptable for well-articulated oral directives to be accepted.

A common thought of personnel might be to involve Police.  The Police have no legal powers to intervene in this situation; they cannot order or insist ambulance personnel provide treatment as they are not in a position to make clinical decisions.  They also have no legal power to overrule the wishes of the parents regarding medical treatment either (for the same reason); it would need to go through the courts.

I would want to start resuscitation and gather further information; you can always stop but you can't "start and make up for lost ground".

I'd need to find out why the mother doesn't want resuscitation.  If she can articulate a succinct, cohesive and convincing argument to rebut the argument that by not doing (or stopping) treatment their child will die, and being very clear, using the words death and die, and show she understands the information then I have no premise on which to continue providing treatment; in fact it would be unethical and illegal for me to do so.


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## zzyzx (Nov 13, 2016)

I can't answer the question because the scenario is so weird and hypothetical.
More realistically, if parents told me not to work up a child at their home and explained that the child had had a chronic illness, then no, I would not work him up, even if they had no DNR.
What you'd have to do regarding calling medical control or not is based on local protocols.


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## RICollegeEMT (Nov 16, 2016)

Sorry guys, I got busy and hadn't had a chance to reply.

Thanks Doc for the input, its definitely helpful to hear the POV from the other side of the desk.

Thank you all for your input.  And yes I realize I threw a very convoluted scenario out there.


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## bakertaylor28 (Jan 28, 2017)

The OP presents a tricky situation. First, this person has no way of verifying authority to act on behalf of the patient- hence she's probably committing a crime by interfering with the lawful duty of a paramedic, to begin with. Secondly, we don't have a DNR on file. (which is an explicit requirement of the law in this types of situations.) Thirdly, in my particular state, DNRs don't apply to first-responders as a matter of law anyways. Hence, I'd be getting on my radio and summoning a law enforcement officer to kindly remove this individual from the immediate scene, with a distinct chance that she might latter end up being arrested.


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