# Scenario: Can you actually treat this patient?



## Handsome Robb (Jun 26, 2015)

A discussion in another thread as well as a discussion I had with my last trainee and another coworker gave me the idea for this thread. I will give you my opinion on the matter after others have chimed in.

You're on scene of a patient who is awake, alert, oriented, ambulatory, not intoxicated, very capable of caring for themselves, not suicidal/homicidal and is able to understand and reiterate everything that is explained to them including the gravity of their situation, the risks associated with refusing care and transport and instructions that are provided to them. There is a witness on scene who is competent as well and signs the AMA form as a witness. 

This theoretical patient is having chest pain and either they called or a family member called, doesn't really matter. 

The 12-lead shows a massive anterior STEMI, their vitals are not terrible but trending towards hemodynamic instability. You explain everything to the patient and tell them they need to go to the hospital for emergent PCI however they adamantly refuse stating "if it's my time it's my time." They do not want to go with you or POV and adamantly state they do not want medical attention of any kind and do not want to be resuscitated however they do not have a signed DNR or POLST. 

As you're leaving you hear a thud and turn around to see the patient ago all on the living room floor. You check and they are pulseless. Can you treat this patient? They're unresponsive now so implied consent seems like it's cut and dry however it's the same condition you were just assessing them for that cause the cardiac arrest and when they were fully capable of making decisions they adamantly refused treatment and transport and acknowledged the fact that this may very well kill them. They stated they do not want to be resuscitated and do not want any help. 

Tell me what you think, keep it civil and support your answers with why not just "mongo do this!" Ready, set, GO!


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## luke_31 (Jun 26, 2015)

Once they are unconscious it falls under implied consent and irregardless to their wishes before they get treated. The only exception would be if they had signed a DNR or advanced directive which would spell out what to do in this situation. Since you already said they didn't have one, then work then up and transport as needed.


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## Handsome Robb (Jun 26, 2015)

Redacted to wait for more insight.


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## luke_31 (Jun 26, 2015)

Implied consent in basic terms doesn't cover what happened before. It would fall under the assumption that the person in the present situation would want treatment even if two minutes ago they were telling you that they would rather die. From the legal stand point you would be covered if you treated the patient after they collapse, but if you continued to leave after they collapsed because that is what they said they wanted, without a legal paper saying that is what they wanted you could be sued for abandonment. Another option in this instance would be to call your online physician, but they would tell you to work the patient and bring them in.


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## Carlos Danger (Jun 26, 2015)

luke_31 said:


> Implied consent in basic terms doesn't cover what happened before. It would fall under the assumption that the person in the present situation would want treatment even if two minutes ago they were telling you that they would rather die. From the legal stand point you would be covered if you treated the patient after they collapse, but if you continued to leave after they collapsed because that is what they said they wanted, without a legal paper saying that is what they wanted you could be sued for abandonment. Another option in this instance would be to call your online physician, but they would tell you to work the patient and bring them in.



So patient autonomy isn't a thing in EMS?


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## chaz90 (Jun 26, 2015)

This is a struggle. Implied consent, to me, would only apply when you don't know their expressed wishes. If they were conscious 5 minutes ago and telling you explicitly what their wishes were, it's hard to justify anything by saying "I imagine they would want to be resuscitated now" when they just told you the exact opposite. 

Patients have the right to make their own decisions in personal medical matters. If an adult patient has an easily treatable form of cancer that has 95% mortality without therapy but that patient adamantly refuses any treatment, we let them. We may try to counsel them, get the family involved, and explain the benefits of treatment, but it is their choice in the end. 

This is really no different, if on a much compressed time scale. I've thought about similar scenarios before. I've gone on an elderly patient for a refusal after complaining of chest pain. There was no acute ischemia evident on the 12 lead or significant issues with his vitals, but I still very much would have liked to treat the patient for presumed cardiac issues and transport him to the ED for further evaluation. I had a long, long conversation with the patient and he repeatedly expressed that he was at the point in his life that he wasn't willing to frequently consent to transport and treatment at the hospital and just wanted to stay at home, even if this possibly treatable condition killed him. He had no signed paperwork, DNR, or MOLST/POLST form of any kind. His wife supported his decision, and he expressed to me many times that were he to go into cardiac arrest, he did NOT wish anyone to attempt resuscitation of any kind. 

We discussed with the patient that he really needed to have a conversation with his PCP and get a DNR/DNI and some type of advanced directive set up. He agreed he would do that when possible, but it didn't change anything for us in the interim. We called med control about this refusal, more to discuss it with him than to obtain orders, and basically all agreed that it would be unethical to perform an arrest resuscitation, against the patient's and family's will, if called back to this residence later in the day. 

Just because it doesn't feel right to us as EMS or other healthcare providers doesn't mean it isn't the right thing for the patient. In most cases, doing the right thing for patient care feels good for us on a moral level, even if it is more work. In this case, the morality falls in a complex shade of gray. Patients have the right to make their own decisions, even if it results in their own death or disability. This hurts and goes against our grain to watch, but it's a necessary part of our job.


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## Clare (Jun 26, 2015)

The law in New Zealand is strongly in favour of the patient (see Health and Disability Commissioner Act 1994 and the HDC Code of Consumer Rights).  

In the situation you describe, the patient has made an advanced directive and a clearly articulated oral directive by a competent patient is sufficient. 

I would politely decline to be involved and not commence resuscitation.


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## cprted (Jun 26, 2015)

As long as there is nothing that I can find that would question their competence, the patient has made their wishes exceptionally clear. He has clearly and lucidly stated that he doesn't want treatment for his MI and understands the course of the condition and does not want to be resuscitated should he go into arrest.  I agree with @chaz90 this is not a case of implied consent, he was competent and make his wishes clear.  

As an adult, I don't need a doctor and a witness to sign an official document to be able to make medical decisions for myself. What I would have done is called up our Doctor and run the whole by them prior to getting the patient to sign AMA. In our system with calls like this we usually end up passing the phone to the patient so the doc and the patient can talk directly. At the end of the day the result will probably be the same, but at least now the conversation has been recorded on a taped line.


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## Brandon O (Jun 26, 2015)

In most areas I don't think oral advanced directives can be honored. May vary by location.


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## Handsome Robb (Jun 26, 2015)

I agree that med control should be included in a situation such as this. Not only to have them discuss/reiterate what you've already told the patient directly but to also have a recorded conversation and if possible have the patient repeat their wishes on the recorded line and also to he DNR orders from the Physician. In this particular situation when I heard them go down I'd do a quick assessment, more than likely begin BLS and call the hospital right back. 

I do not personally think implied consent applies here since it's the same condition they denied treatment after being informed of everything involved. Like @chaz said it will be more work but ultimately our job is to be a patient advocate and if that means you need to spend some extra time on scene talking with the patient and on the phone with a physician then that's what needs to be done. I'd argue that you could even go as far as getting the patient's Primary Care Provider on the phone to help get the ball rolling for a DNR/I or POLST/MOLST and possibly even get one filled out and faxed or emailed to the patient after having them discuss it on the phone with their PCP if that was an option. 

This is a good discussion let's keep it going. I didn't start this to tell people that they're wrong, I'm really very interested in people's answers and their rationale behind them. 

While I could see the potential for legal action for not acting I personally believe that there's just as much potential for legal action if you were to disregard their wishes and resuscitate them either from them if they had a good outcome without neurological deficits or the family if they had a poor outcome. 

I don't want to ask for legal advice but I'd love to hear a lawyer's take on this. I do understand it's tough to answer from a legal standpoint since laws vary so greatly from location to location.


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## luke_31 (Jun 26, 2015)

Exactly why I would have to operate under implied consent even if the patient told me they didn't want anything done. The laws where I work don't allow me to accept a verbal request from the patient in this situation. I would try and discuss this with my online physician, but it would have to be worked up unless I wanted to risk my job and license.


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## NomadicMedic (Jun 26, 2015)

That's the kind of thing it would be great to have a recording of... I wonder how long it will be before EMS wears mandated body cams and is able to create a video/audio record of the patient's refusal. Video evidence would be hard to refute.


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## Brandon O (Jun 26, 2015)

Making end-of-life decisions is a difficult and complex task that should be done in a calm moment with extensive medical advice. That's why we have all these formal pieces of paper that we get doctors to sign.


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## chaz90 (Jun 26, 2015)

Brandon O said:


> Making end-of-life decisions is a difficult and complex task that should be done in a calm moment with extensive medical advice. That's why we have all these formal pieces of paper that we get doctors to sign.


Right, this is absolutely optimal. Talking to your physician, prior to any event, with witnesses present, and documents signed in triplicate is the gold standard. At the same time, what are we to do when this hasn't been done in advance? Just like so many other things in EMS, we have to deal with the situation as it's presented to us, not how we'd like to see it.


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## Brandon O (Jun 26, 2015)

No doubt. But I think many people feel that in that situation, the safest route is to err on the side of intervening.


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## Clare (Jun 26, 2015)

I don't understand why people seem to be so scared of doing what the patient wants.  A competent patient has the right to make informed choices regarding what healthcare they receive, including in the future.  They cannot insist upon treatment that is not clinically indicated but they can insist that they do not receive certain treatment, e.g. resuscitation from cardiac arrest.  In the situation described, the patient has made a clear advanced directive.  Just because it's not in writing does not mean that it's any less valid.  The great thing about getting ePRF is that audio can be recorded and added to the ePRF so it would be absolutely clear what the patient said.  

Often the family or whomever is at the scene and knows the patient will disagree with them regarding intervention, well, that doesn't really matter because while the view of the family (or whomever is there) must be taken into account, they do not have the right to insist upon or decline treatment.  For example, if there was a family member present who said that the patient should be resuscitated, whilst their view must be accounted for, they cannot overrule the informed choice of a competent adult patient.  

Yes, it's very difficult to _*not *_do something especially when you are right there and _*can *_do something, but if the patient has made an informed choice not to receive the treatment in question then their wishes must be respected, as hard as that may be.


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## Akulahawk (Jun 26, 2015)

This is one (very big) reason why I carried a comm device with me into every scene I responded to. If I had signed AMA forms and good supporting documentation and then the person (no longer a patient at that point) fell over dead, I'd have to call med control. Yes, people have their right to be stupid and die, however my hands may be tied as to what I can legally honor as a valid with respect to patient resuscitation wishes.

You have to know what your system requires/allows in this situation. When I was in the field, we were directed specifically that a DNR order, a POLST, or a competent DPAHC could stop/prevent the full-tilt resus boogie. In effect, without the paperwork, an EMS patient could refuse all care up to the moment the patient lost consciousness and then implied consent kicked in.

If I can call for orders, I might be able to get an order to cease efforts... and thusly honor patient autonomy.


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## NomadicMedic (Jun 26, 2015)

Clare said:


> I don't understand why people seem to be so scared of doing what the patient wants.  A competent patient has the right to make informed choices regarding what healthcare they receive, including in the future.  They cannot insist upon treatment that is not clinically indicated but they can insist that they do not receive certain treatment, e.g. resuscitation from cardiac arrest.  In the situation described, the patient has made a clear advanced directive.  Just because it's not in writing does not mean that it's any less valid.  The great thing about getting ePRF is that audio can be recorded and added to the ePRF so it would be absolutely clear what the patient said.
> 
> Often the family or whomever is at the scene and knows the patient will disagree with them regarding intervention, well, that doesn't really matter because while the view of the family (or whomever is there) must be taken into account, they do not have the right to insist upon or decline treatment.  For example, if there was a family member present who said that the patient should be resuscitated, whilst their view must be accounted for, they cannot overrule the informed choice of a competent adult patient.
> 
> Yes, it's very difficult to _*not *_do something especially when you are right there and _*can *_do something, but if the patient has made an informed choice not to receive the treatment in question then their wishes must be respected, as hard as that may be.



All very interesting points, however most of what you mention is simply not valid or legally defensible in the United States.

A paramedic who did not resuscitate a witnessed cardiac arrest would almost certainly be named in a civil suit, regardless of what that patient said prior. 

U.S. = sue everyone.

Most paramedics here lack the personal financial resources to fight any type of legal battle and the EMS agency would most likely not support the paramedic.

And of course there is the old "you're going to lose your license" thing. Whether or not that's true, I'm pretty sure nobody really wants to be the first to try it.

So, without a valid, signed DNR, a medic is going to work that arrest until they get a doctor to say stop.

I envision a doc would say, "you're obligated to work it. If you get ROSC and he wakes up in the ICU and refuses care, we'll deal with it. If you don't get ROSC, well, he's still dead..."


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## Clare (Jun 27, 2015)

DEmedic said:


> All very interesting points, however most of what you mention is simply not valid or legally defensible in the United States.



But I don't understand how that can be so?

Do your patients not have the right to make informed choices about what health care they receive?
Does this not extend to making choices regarding future care?

With those two principles in mind if a patient (as described here) clearly articulates a wish not to receive resuscitation from cardiac arrest then how can the greater evil be to honour that wish vs. not doing so and providing said resuscitation? Surely physically providing CPR, defibrillation, IV access, IV medicines and some form of airway intervention (even if it is an LMA) when the patient has expressly made a clear advance directive not to do so amounts to assault?

Regardless of what the family think _*should *_be done (as often the family will disagree with the patients choice) there must be some producible justification on patient rights for those who act in accordance with the wishes of the patient.  

I would be very interested to see what your body who sets patient rights and responsibilities of healthcare personnel has to say about that, surely whatever you call your patients rights document or charter or code or whatever includes such provisions for informed choice and advanced directives. 

As an example, you can read ours here http://www.hdc.org.nz/the-act--code/the-code-of-rights/the-code-(full)


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## PotatoMedic (Jun 27, 2015)

Patients do have that right.  But if it is not in writing family may be inclined to sue to try to make an easy buck.


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## Akulahawk (Jun 27, 2015)

Clare, unfortunately for the US, we have a _very_ litigious society. It's more legally defensible to provide care to someone that (quite literally) refused your assistance a few seconds ago than to withhold care absent some legally binding paperwork or a directive by a DPAHC (confirmed in writing). In short, if I'm perceived as withholding care, then I get into bigger trouble than if I don't.


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## Clare (Jun 27, 2015)

Akulahawk said:


> Clare, unfortunately for the US, we have a _very_ litigious society. It's more legally defensible to provide care to someone that (quite literally) refused your assistance a few seconds ago than to withhold care absent some legally binding paperwork or a directive by a DPAHC (confirmed in writing). In short, if I'm perceived as withholding care, then I get into bigger trouble than if I don't.



But again, if a competent patient has said to you with words that came out of their own mouth that they do not want resuscitation in the event of cardiac arrest then I do not understand how that cannot be considered an advance directive? 

What does your code or charter or document of patient rights say about this?


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## PotatoMedic (Jun 27, 2015)

Sadly if it is not in writing then it is the paramedics word verses families word.  And the jury will always side with the family.  Yes the patient wished one thing but family may not agree or they will see an easy way to make money.


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## Akulahawk (Jun 27, 2015)

Worse still, even if it _is_ in writing in the form of a witnessed refusal, families can still sue, cause some bad PR, and it's often cheaper to pay off the family and/or terminate the employment of a reasonably replaceable EMS worker than it is to defend against the lawsuit... even if the lawsuit is bogus. If you provide care under implied consent, regardless if the patient survives, lawsuits typically die early on because of implied consent and there's always the "PR" aspect where you "did everything." If the patient does survive and sues, juries aren't likely to say "yep, you should have died, they should have ignored their training and let you die, and therefore you wouldn't have been able to sue on your own behalf..." 

It's very much a real pain in the backside. Don't get me wrong, I'm all for patient autonomy. If you choose to refuse care and it's witnessed, you should be allowed to keel over in front of me without me getting into trouble by walking away. Absent a DNR or POLST order... my hands are tied.


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## Handsome Robb (Jun 27, 2015)

Clare, laws here vary so much state to state, county to county and city to city it makes for a very difficult discussion on things with a legal aspect.

I'm all for patient autonomy and personally in this situation would call a Doc and have them speak with the patient on the issue on a recorded line and if they insist on nothing being done then have them say that on the recorded line. After signing the AMA with a witness signature as well if they crumped in front of me I would start hands only CPR and immediately call the same facility back and request the same physician for termination orders. Depending on the doc I may or may not get them. 

If they were able I would also try to get the PT's PCP on he phone and initiate proceedings for a DNR/POLST/MOLST. With our new POLST system in my state it's very plausible that I could have a POLST faxed or emailed to myself and the patient with the required signatures which would allow me to cease/not begin efforts if they did in fact arrest in front of me. An example of variances between states is some areas will honor DNRs on a Rx pad with a Physician's signature and license number or an Advanced Directive with the same information whereas where I'm at unless it's a transfer from hospital to nursing home I cannot accept the above noted versions and have to have a state issued DNR or POLST form signed by a physician. I cannot honor an Advanced Directive without consulting with online medical control, unfortunately. 

In my opinion it's a broken system however because the culture in the U.S. is so litigious we truly do have to provide care, especially in a situation like this, in a fashion which covers our own ***. It sucks but it's the system we're stuck with for now. 

As I said before I fully support patients being able to make informed decisions about their healthcare however I would have to jump through some flaming hoops to do so, which I'm fully capable and willing to do however some and Id argue that many providers, unfortunately, are not willing and have had CYA and "you will lose your certification and be sued drilled so far into their heads by our model of education that it is just downright easier to follow your written protocols in a situation like this and to let the hospital sort out the legal aspect of it. It's not right but it's a fact of life as an EMS Provider in the U.S.

Another big reason I personally think our hands are so tied in situations like this are due to our severe lack of education in legal issues applying to EMS as well as end of life decision making/care as well as a general lack of education. We aren't trusted to make big decisions like required in this situation without calling for help because we're still viewed as a vocational field filled with technicians rather than a profession filled with well educated clinicians.


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## Brandon O (Jun 27, 2015)

Just to play devil's advocate, there is probably some value to formalizing the process of advanced directives. How seriously do we want to take every statement someone makes about their future care?

Even with properly-prepared directives it's not uncommon for patients to change their mind when the time actually comes. That's undoubtedly even more true for all the passing remarks about "Nah, I don't want none of that."

The idea of implied consent from patients who can't say otherwise is that really, most WOULD want care when in extremis, even if they thought differently when their situation was more theoretical. People don't want to die. This is true for the majority of patients, and overriding that default should be a decision made thoughtfully and carefully.

Ahead of time. In a doctor's office.


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## Chewy20 (Jun 27, 2015)

Say you do not work it, and then the family turns around and sues you. That is a CRAPPY thing to fight in court and I think we all know the outcome, plus your face will probably be on the news. The way things are nowadays I would much much rather deal with a pissed off alive dude that we got ROSC on, then a pissed off family with a dead relative saying they did not even try to work it. Whether he said it or not, the family will usually always win in cases like this unfortunately.


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## joshrunkle35 (Jun 27, 2015)

Start CPR. Contact online medical control. Explain situation. Let the doctor make the decision. Document. The end.


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## ERDoc (Jun 27, 2015)

As the person who would be answering the medical control call, I would tell you to work it.  You are not dealing with "the same condition prior to the cardiac arrest."  The cardiac arrest is a new condition.  Without anything in writting, you are on the hook.  As Brandon O said, advance directives should be done ahead of time, in the appropriate setting where proper thought and discussion can be had, not when the pt is in extremis.  Worse case scenario, you work it and the pt dies.  Best case, you work it, the pt lives.


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## Clare (Jun 27, 2015)

In New Zealand, patient rights are covered by the Code of Health and Disability Services Consumers' Rights and this covers all healthcare patients and personnel including ambulance personnel.  It became law in 1996. 

Right 7,5 states every consumer may use an advance directive and advance directive is defined in the Code as meaning "a written or oral directive - (a) By which a consumer makes a choice about a possible future health care procedure; and (b) That is intended to be effective only when he or she is not competent".

What is the equivalent of the HDC code in the United States? Surely it must contain similar provisions and these can justify honouring a competent patient's advanced directive (even if the family jump up and down about it - noting the family has no legal say in the matter unless they have an EPOA)?


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## Brandon O (Jun 27, 2015)

Advance directive policies and laws are all state by state.


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## DrParasite (Jun 27, 2015)

The condition the person refused care for is the STEMI.  The cardiac arrest, while a result of the STEMI, is a different condition.  The patient was conscious when they refused; now their condition has changed, and it's no longer the condition same condition.   

I could much easier defend working a cardiac arrest than not working one.  Even if an AMA refusal was signed for the stemi 10 minute ago.


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## Handsome Robb (Jun 28, 2015)

@ERDoc with that line of thinking does that not make DNRs that are invoked on the ER and ICU every day across the country invalid since the patient in those circumstances is also in extremis and cannot discuss it "ahead of time, in the appropriate setting where proper thought and discussion can be had."

I agree that in ideal circumstances this conversation should be had in a setting without pressure and with unlimited amounts of time to discuss and confirm exactly what the patient is requesting however as an ER Doc I know that you're fully aware that this isn't always a luxury granted to us in emergency medicine. 

Not trying to be argumentative, just bringing up a point and something I've witnessed happen in the ER more than a few times.


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## RedAirplane (Jun 28, 2015)

Suicidal people jump off buildings but may have second thoughts while accelerating through 9.8 m/s/s toward a poor unsuspecting Buick...


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## Ewok Jerky (Jun 28, 2015)

Handsome Robb said:


> @ERDoc with that line of thinking does that not make DNRs that are invoked on the ER and ICU every day across the country invalid since the patient in those circumstances is also in extremis and cannot discuss it "ahead of time, in the appropriate setting where proper thought and discussion can be had."


The idea is you sit down and talk with the patient for 30-40 minutes explaining various situations, treatments, procedures, and outcomes. You do this is in a calm controlled environment where the patient can think and ask questions. Then they can go home and talk with family and come back with more questions before signing. That way, when they are in extremis, the conversation was had (syntax?) with proper thought and consideration.

Obviously you can't do this in the pre hospital setting, but done with the PCP makes the job of the ED and ICU much easier.


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## Clare (Jun 28, 2015)

Ewok Jerky said:


> Obviously you can't do this in the pre-hospital setting, but done with the PCP makes the job of the ED and ICU much easier.



Rubbish.  Why should a patient not be able to make an advanced directive to ambulance personnel, or for that matter, any other healthcare professional? The thing we must keep in mind is that it is the choice of the patient to do so and we should respect their wishes, provided they are competent to make decisions and articulate them.


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## Ewok Jerky (Jun 28, 2015)

Because when someone is about to crash is not a good time to discuss sedation, intubation, ventilators, central lines, Foley caths, PICCs, LVADs, ICDs, dialysis, etc. When **** hits the fan on a call there is no time for discussion.

Look I'm all for patient autonomy, that is why these conversations should happen BEFORE we pick them up in the ambulance. Maybe you kiwis are more civil than we are in 'Merica, but even WITH an advanced directive if the family wants we worked we work it more often than not. Am I happy about that? No. But I would rather give the LIVING family peace knowing we tried. Plus, the dead patient can't sue you but the living family can.


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## Carlos Danger (Jun 28, 2015)

Clare said:


> Rubbish.  *Why should a patient not be able to make an advanced directive to ambulance personnel, or for that matter, any other healthcare professional?* The thing we must keep in mind is that it is the choice of the patient to do so and we should respect their wishes, provided they are competent to make decisions and articulate them.



For several reasons, but primarily because, as Ewok pointed out, the decision to refuse life-saving intervention should be made only after lengthy discussion and careful consideration of the clinical situation and all of the possibilities. The patient needs to truly understand what they are asking for. Is a paramedic really the right person to educate the patient on and answer specific questions about all of the complex possibilities that could occur well after the EMS encounter? And is the patient's living room when they are having active chest pain or difficulty breathing really the time and place to do it? 

The other major reason is legal. In America, the default assumption from a legal standpoint is that patients always want life-saving care, and are legally entitled to it. Of course patients have a right to refuse care, but in order to do so they have to go through a brief but important process with their physician so that everyone can be sure that they really understand what they are asking for, and that it is objectively documented in a way that is unambiguous and leaves no doubt in anyone's mind that the patient made the decision on their own, after considering all relevant information. It's not a perfect process, but the thinking is that it is better to err on the side of providing care to someone who may not want it than it is to not provide care to someone who really does. 

It's not that patients have any less right to self-determination in the field, it's that such an important decision with such major implications (for not only the patient but their clinicians) has to be made in such as way that protects not only the patient's wishes, but also the legal rights of the clinicians involved.


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## Clare (Jun 28, 2015)

Ewok Jerky said:


> Maybe you kiwis are more civil than we are in 'Merica, but even WITH an advanced directive if the family wants we worked we work it more often than not.



I really can't believe I am reading that - no, like, really.  That's pretty horrendously disrespectful to the wishes of the patient.  I would like to see where it says the family has a right to insist that you provide treatment that is not indicated (in this case, because the patient has refused it).  

Surely whatever patient rights law gives the patient the option to make an advanced directive, and I'd bet it doesn't say "the family can overrule it".  Therefore, by converse of same, surely that should also provide you with protection against not acting.  



Remi said:


> For several reasons, but primarily because, as Ewok pointed out, the decision to refuse life-saving intervention should be made only after lengthy discussion and careful consideration of the clinical situation and all of the possibilities. The patient needs to truly understand what they are asking for. Is a paramedic really the right person to educate the patient on and answer specific questions about all of the complex possibilities that could occur well after the EMS encounter? And is the patient's living room when they are having active chest pain or difficulty breathing really the time and place to do it?



If the patient is competent by whatever definition of competency you use, then yes, they have the utmost right to refuse care and make an advanced directive.  From the perspective of ambulance personnel, the patient would be refusing or making advanced choices regarding care that can be provided or facilitated by them.  For example, in this situation, ambulance personnel can provide treatment for STEMI and cardiac arrest and facilitate transport for pPCI, all of which the patient refused (which by proxy, for cardiac arrest, is an advanced directive given he was not _*yet *_in cardiac arrest).  I would be perfectly comfortable with discussing this with the patient and answering questions as it is something I know well.  If they wanted to make an advanced directive for something "in the future" other than what is right infront of me then they need to discuss that with their GP or whomever.  However, from the perspective of ambulance personnel, I am not referring to that.  




Remi said:


> The other major reason is legal. In America, the default assumption from a legal standpoint is that patients always want life-saving care, and are legally entitled to it. Of course patients have a right to refuse care, but in order to do so they have to go through a brief but important process with their physician so that everyone can be sure that they really understand what they are asking for, and that it is objectively documented in a way that is unambiguous and leaves no doubt in anyone's mind that the patient made the decision on their own, after considering all relevant information. It's not a perfect process, but the thinking is that it is better to err on the side of providing care to someone who may not want it than it is to not provide care to someone who really does.
> 
> It's not that patients have any less right to self-determination in the field, it's that such an important decision with such major implications (for not only the patient but their clinicians) has to be made in such as way that protects not only the patient's wishes, but also the legal rights of the clinicians involved.



I think the common assumption of implied consent the world over is that patients want life-sustaining treatment until proven otherwise.  

So what you are saying is that in the United States, (a) an advanced directive can only be made to a doctor and not ambulance personnel or other healthcare providers and (b) that it must be in writing, oral directives are not acceptable? Is there a specific place where this is spelled out? 

From what the other bloke wrote, it doesn't sound like an advanced directive actually protects what the pt wants because the family can show up and say "that doesn't matter, we want ...." and ambulance personnel will provide it regardless.  

To me this makes absolutely no sense, because unless there is a specific provision within whatever charter or code or document of patients rights you operate under gives the family the ability to override what the patient has directed, then what they want has absolutely no bearing on anything at the end of the day.  Of course what the family say must be taken into account, but the therapeutic relationship is between the patient and healthcare personnel (including ambulance personnel) and not the family (unless of course they have EPOA).


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## NomadicMedic (Jun 28, 2015)

I guess you're lucky you don't live in the states.


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## TransportJockey (Jun 28, 2015)

Clare said:


> I really can't believe I am reading that - no, like, really.  That's pretty horrendously disrespectful to the wishes of the patient.  I would like to see where it says the family has a right to insist that you provide treatment that is not indicated (in this case, because the patient has refused it).
> 
> Surely whatever patient rights law gives the patient the option to make an advanced directive, and I'd bet it doesn't say "the family can overrule it".  Therefore, by converse of same, surely that should also provide you with protection against not acting.
> 
> ...


In my state, the NOK can actually revoke a DNR on scene. And if the family member has a healthcare POA, even if the patient is adamant about being a DNR and has the appropriate paperwork, the POA can override that. 
As for the base scenario in the OP... I honestly don't know what I'd do. I know I'd be calling Med Control right then and there, and probably initiate BLS care... There's no one good answer for this, especially since state laws vary so much.


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## joshrunkle35 (Jun 28, 2015)

A good example about advanced directives would be a personal example of one of our Grandparents:

When he's in the hospital in bad shape, he keeps wanting a DNR. He wants no care, he wants to die. The family usually tells him, "Hey, let's wait and talk about this tomorrow." But, nope, his mind is made up. He doesn't want to live anymore. He's in a lot of pain. 

Then...he gets home, feels all right and wants to live. He sees his doctor for a checkup and wants to live because he's in good health. He decides that he wants to be resuscitated in the event that something happens. 

The truth: He suffers from depression. It was very late onset in life. Only in the last few years. He takes medication for it. While he is alert to person, place, time and event during an emergency, most people don't realize that he is on a medication for depression and that he hasn't taken it at the appropriate or allotted time during the emergency. Most people would see the STEMI, but miss that he is also depressed, or see it as, "He's having a bad day because he is having a STEMI." While he may be AAOx4, he is in a compromised mental state, which needs to be fixed before such decisions should be made. 

This is a true story and something we've honestly been dealing with recently.


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## Brandon O (Jun 28, 2015)

Josh has a good example of the complexities.

Clare: part of the issue here is that in real life, things often aren't clear-cut. It's not unusual in (for example) the ICU setting for conflicting information to be available regarding a patient's wishes -- multiple family members, directives of various sorts and defensibility, the judgment of the treating team, etc. While these things are muddled through on a daily basis, when in doubt most people would err on the side of treating, since that's a mistake you'll get to make again. And in the typical prehospital setting, with providers of far less training, more chaotic circumstances, less time to reflect, and fewer resources available, this is even more true.

Again, state law varies, but typically EMS protocols do explicitly state something along the lines of "when in doubt, resuscitate." It's also common that efforts are made to simplify EMS care by limiting the number of documents we can honor -- many states have a single simplified DNR form that needs to be physically present for field crews to avoid resuscitation. That way we don't have to get out our spectacles and inspect ten different contradictory pieces of paper while CPR is going on, never mind any additional opinions from the peanut gallery.

I agree that if a clearly-valid directive exists refusing care, it should not be possible to override that. The dilemma arises if the directive is called into question -- i.e. you have family saying, "No, that's not right, he signed that ages ago but lately he's been saying he wants everything done."


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## ERDoc (Jun 28, 2015)

Handsome Robb said:


> @ERDoc with that line of thinking does that not make DNRs that are invoked on the ER and ICU every day across the country invalid since the patient in those circumstances is also in extremis and cannot discuss it "ahead of time, in the appropriate setting where proper thought and discussion can be had."
> 
> I agree that in ideal circumstances this conversation should be had in a setting without pressure and with unlimited amounts of time to discuss and confirm exactly what the patient is requesting however as an ER Doc I know that you're fully aware that this isn't always a luxury granted to us in emergency medicine.
> 
> Not trying to be argumentative, just bringing up a point and something I've witnessed happen in the ER more than a few times.



You bring up a good point.  I have had the "how much do you want done?" conversation with many pts that are circling the drain.  In that case though, I was there are personally had the conversation with the pt and know exactly what was discussed.  In the case where a crew calls up, I was not there and do not know exactly what was discussed.  If they are going to call and place the responsibility for making the decision on me, then I am going to err on the side of caution and say work it since I never interacted with the pt.  As for the legal issues, I doubt you will find much precedence for a case like this so it will basically be up to the jury to decide your fate.  Who wants to roll those dice in the US?   Ideally, we should not be practicing medicine based on the threat of legal action, but here in the US, where anyone can sue anyone and you can pay out millions of dollars because your hot coffee is, well, hot, it's not a chance I want to take.  I have a wife, kids, house and career that I would like to keep.


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## Clare (Jun 28, 2015)

ERDoc said:


> Who wants to roll those dice in the US?   Ideally, we should not be practicing medicine based on the threat of legal action, but here in the US, where anyone can sue anyone and you can pay out millions of dollars because your hot coffee is, well, hot, it's not a chance I want to take.  I have a wife, kids, house and career that I would like to keep.



The cost of doing so and significant legal protections for healthcare professionals (including ambulance personnel) just make this simply so nearly impossible that in all practical reality it is, to my knowledge, impossible, to achieve this here.

You would need to file suit for exemplary damages, for example, for lost earnings of the person who was not resuscitated, and the only real way you could do this would be to prove gross negligence on the part of ambulance personnel.  The law regarding competency and advanced directives and patient choice and such is so in favour of the patient (and by proxy, the ambulance personnel) that it would be fighting such an up hill battle I seriously doubt you would find a lawyer willing to support you.  You could represent yourself against the ambulance personnel involved by calling them to a civil dispute at the small claims tribunal but the cap is something like $5,000 and the ambulance service and the union would go after this like a house on fire to protect you. 

It is legally not possible to have the ambulance service named in a suit for damages (given our comprehensive medical misadventure compensation legislation prohibits this) and a quick search of judicial decisions online from the Ministry of Justice from 2003 onwards reveals that at no time has the ambulance service been sought for exemplary damages either.  

I guess different countries are different and that's fine, but I guess that I am lucky that I never have to worry about anything like this ever and I know that if I do cause harm to somebody by accident that there is a comprehensive system set up to not only treat and look after that person and assist them in whatever they need for the rest of their lives but to also protect me from being named in some million dollar American TV style lawsuit.


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## ERDoc (Jun 28, 2015)

You have no idea how lucky you are.  EMS agencies are constantly named in suits here.  There is no protection.  We (ER and EMS) are required by law to see/treat everyone without expectation of payment, yet have no protection from any lawsuits, legitimate or frivolous.  Even in places that have tried to add some degree of protection, the lawyers find ways around it.


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## Carlos Danger (Jun 28, 2015)

In theory, a system that relies on the threat of civil judgements to enforce competent decision-making is preferable to one where regulation specifies every action and criminal prosecution is the punishment for non-compliance.

In reality, we have unfortunately drifted to a place where we have to deal with the worst aspects of both approaches.


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## Jim37F (Jun 28, 2015)

Who called us back a second time? Yes the (compitent) patient has a right to refuse treatment and/or transport, they also have the right at any time to invalidate a DNR order by simply telling me to ignore it. Also, my protocol says that even in the presence of a properly filled out and signed DNR/POLST/AHCD etc if any family member on scene objects to withholding CPR, we are to immediately initiate BLS measures and contact medical control.

So for our hypothetical STEMI patient who AMA'd earlier, if we get re-dispatched, either they decided that yeah, they do want treatment and called before coding, or family wants treatment and called, both cases would mean beginning resuscitation even with a paper DNR present. Now if a SNF staff or member of the public called, if the DNR is present, well then we follow the DNR


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## Summit (Jun 28, 2015)

That would have been part of my conversation with medical direction before departing the scene: "so doc, what happens if this guy dies in front of me? CPR or no?"

It would be unethical to resuscitate.

it would be arguable in court or before a professional board that you should have resuscitated.


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## RedAirplane (Jun 29, 2015)

To paraphrase my instructor, in the US, as an EMS provider, it's not a question of IF, but of WHEN and HOW OFTEN you get dragged into court.


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## Ewok Jerky (Jun 29, 2015)

Clare, the whole idea of an advanced directive, around here anyways, is to clear up the patients wishes, with informed consent, in writing, with a witness and a physician, BEFORE they code. When executed properly, a grieving family member can be shown the paperwork, reminded of their loved one's wishes, and resuscitation can be stopped or not initiated in the first place. In my short career I have had to proceed with contacting on line med control once to talk with the family and once called the PCP. In the pre hospital setting I have never worked a code or transported a pt with a DNR but certainly family members (usually only one) often try to get us to work it.


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## Ewok Jerky (Jun 29, 2015)

Section 823, page 4, section F

And here is a local protocol for northern California, which states if family says work it, start BLS and contact mes control. Like I said the one time I had to do this the physician on the phone was able to convince the family to stop.

FWIW I don't think anybody here disagrees with you about ethics or patient autonomy, its just that for most of us our hands are tied. Also, I don't think this situation occurs all too often that we are transporting DNRs every day.


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## Jed Bishop (Jun 30, 2015)

Patient refusal of treatment during signs and symptoms is acceptable, let them be and leave.  If they refuse to sign an AMA, contact your medical director. If they were still responsive during a MI and said "no treatment", let them be and leave. Same contact with your medical director. If you are still there and "they hit the floor and are unresponsive", your next response is dictated by a valid DNR or POLST and Implied Consent for treatment direction. Contact your medical director. There's no reason to make these decisions on your own. Keep your decision process simple. The only issue I see is the when the patient verbally informs you "no treatment" during the first two scenarios, does the patient present cognitive knowledge of the risks of " no treatment"?  How many "jumpers" have thought " this was a bad idea", on the way down. And, I should have listened to that emergency responder. 
Just thinking.....Jed.


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## Brandon O (Jun 30, 2015)

Jed Bishop said:


> How many "jumpers" have thought " this was a bad idea", on the way down. And, I should have listened to that emergency responder.
> Just thinking.....Jed.



According to some research, most of them.


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## Noncreative (Jul 2, 2015)

Remi said:


> So patient autonomy isn't a thing in EMS?


Well, it is with a conscious and competent patient.  But without a valid DNR, you're leaving yourself open to abandonment.


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## stethoscope (Jul 8, 2015)

In my state, implied consent would be valid here unless they have a DNR. Only recently were we even allowed to follow DNR's for codes. We were taught that if there is any question of whether or not you should treat a code, treat it.


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## Tigger (Jul 8, 2015)

Noncreative said:


> Well, it is with a conscious and competent patient.  But without a valid DNR, you're leaving yourself open to abandonment.


 Citation please. 



stethoscope said:


> In my state, implied consent would be valid here unless they have a DNR. Only recently were we even allowed to follow DNR's for codes. We were taught that if there is any question of whether or not you should treat a code, treat it.


 Also citation. If people were not honoring DNRs that would be a serious issue. 

Also, I'm not sure how many times I can say this and I mean this more generally, but the patient's wishes need to be respected. Sometimes things happen too fast for advanced directives to be properly completed but the patient has made his or her wishes clear. While it is fine to start efforts in an ambiguous situation, it should be someone's priority to make contact with medical control to get cessation orders. There is not a conspiracy of family members killing their loved ones and then saying "oh they had a DNR I just can't find it" and EMS needs to stop pretending that this exists. It's disrespectful to both the patient and the family.


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## MrLegsGuy (Aug 3, 2015)

Handsome Robb said:


> A discussion in another thread as well as a discussion I had with my last trainee and another coworker gave me the idea for this thread. I will give you my opinion on the matter after others have chimed in.
> 
> You're on scene of a patient who is awake, alert, oriented, ambulatory, not intoxicated, very capable of caring for themselves, not suicidal/homicidal and is able to understand and reiterate everything that is explained to them including the gravity of their situation, the risks associated with refusing care and transport and instructions that are provided to them. There is a witness on scene who is competent as well and signs the AMA form as a witness.
> 
> ...


Without reading any of the replies, I'm going  to say without question I would begin CPR immediately. I would assume a conflicting medical problem altered the mental status of this man. There is no way to know for sure. How was his cardiac output? How strong was his pulse? OX? BGL? History of diabetes? Was the clot sudden or gradual? 
I'm sorry but without a proper SAMPLE history, I can't offer a definitive answer


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## Flying (Aug 3, 2015)

Assume altered mental status? Differentiating between sudden and gradual clots? What?

It says in the first sentence of the scenario:
*You're on scene of a patient who is awake, alert, oriented, ambulatory, not intoxicated, very capable of caring for themselves, not suicidal/homicidal and is able to understand and reiterate everything that is explained to them including the gravity of their situation, the risks associated with refusing care and transport and instructions that are provided to them. There is a witness on scene who is competent as well and signs the AMA form as a witness.*

This is clearly meant to be a discussion about consent. Either start reading the words in front of you or stop trolling us.


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## MrLegsGuy (Aug 3, 2015)

Flying said:


> Assume altered mental status? Differentiating between sudden and gradual clots? What?
> 
> It says in the first sentence of the scenario:
> *You're on scene of a patient who is awake, alert, oriented, ambulatory, not intoxicated, very capable of caring for themselves, not suicidal/homicidal and is able to understand and reiterate everything that is explained to them including the gravity of their situation, the risks associated with refusing care and transport and instructions that are provided to them. There is a witness on scene who is competent as well and signs the AMA form as a witness.*
> ...



This just simply doesn't make sense considering I would never trust someone else's judgement over my own.


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