# To Work, or Not To Work, That Is The Question



## MissTrishEMTB08 (Sep 22, 2008)

Okay, Ive had my license for a couple of months but I just started a job at a transport service.

I have a question pertaining to work yesterday.

We were transporting a hospice patient from a private residence to the hospice house, we were met by a case worker and the patients family at their home and the patient who was laying naked, in a reclined chair. She was cyanotic and cool, respirations were irregular and the only way I could count them was by the the fluidy raley inhalation. She had severe pitting edema in her legs and her stomach was extremely distended due to her liver and she was covered in crusty sores and her arms were pencil thin (if you looked at her from the top she looked like a 95 pound lady, if you looked at her lower half she looked like 200 pounds, to give you an idea of how distended and swollen she was) The family could NOT find her DNR but her husband came along for the ride in the back with my partner. I was the driver (and this is the 3rd time Ive ever driven an ambulance, Im still really bad at it!). 

I hear my partner in trying to get her to respond, and her husband tells him that shes always like that, and kept telling my partner to ignore her, ignore her, dont even look, this is how she always is. He had a living will and continually asked why we couldnt accept the living will instead of the DNR. My partner explained that he HAS to work her by law.

Well we get to the hospice and the husband goes in to sign the hospices DNR and I go to help unload the stretcher and my partner goes _I think the patients dead!_. And yes, she was very dead. 

In the end we got a copy of the Hospices DNR for his files and all is good (we called our supervisor two hours later to see if we had to notate it any specific way on our paperwork to find out we are supposed to call when she died, we never told them that the patient didnt have a DNR with her until we got to hospice.). The hospice nurses said that the case worker should have never let her be transported.

If I had been in the back, I would have worked her because we cant accept living wills, we must have, *in hand*, a valid DNR. My question is, would every one else here work her? I know the husband didnt want her to suffer anymore, but they didnt have the valid paperwork and if the husband wanted to be a real d!ck head he could go back and sue the crap out of the company, couldnt he? No DNR, didnt work her when she died.

(And please note, I didnt know she was dead til I got out, I heard conversations about not looking at her, this is how she always is,  but my parnter never indicated that she was dead until we were there.)


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## flhtci01 (Sep 22, 2008)

Without paperwork, they would get worked.

Just curious, how long was the transport?


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## JPINFV (Sep 22, 2008)

MissTrishEMTB08 said:


> If I had been in the back, I would have worked her because we cant accept living wills, we must have, *in hand*, a valid DNR. My question is, would every one else here work her? I know the husband didnt want her to suffer anymore, but they didnt have the valid paperwork and if the husband wanted to be a real d!ck head he could go back and sue the crap out of the company, couldnt he? No DNR, didnt work her when she died.



This is one of the few cases where I'll actually say, "depends on local protocol." Where I worked, a verbal request to withhold/withdraw resuscitation by an immediate family member was to be respected. As such, in my old system I would not have worked her. Unless your local protocol includes such a clause, then yes, I would have worked her.


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## Ridryder911 (Sep 22, 2008)

Here's an idea.. .think. Get that old doctor of yours a chance to work. Call medical control or even the patients hospice physician and get a verbal DNR. Give a brief history of the patient and most ER physicians, medical control will authorize a DNR. A verbal order is enough until the physician can order one, a living will in some states can be the same as a DNR with specific conditions of what the patient wants done and not done. Hence the *Living Will*.

R/r 911


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## JPINFV (Sep 22, 2008)

^

That doesn't help if the system doesn't have online medical control at the EMT-B level or allow telephone orders from a patient's physician (PMD must be present and sign the PCR, which, thinking about it, doesn't really make it all that much of a verbal order).


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## beachemt (Sep 22, 2008)

I dont know where you were but in VA if i dont have a DNR and its the original we work it. We had a lady last night who made it very clear that this was the last time she wanted to be transported to the hospital because she had a DNR but was ok with going last night. We had the copy but both paramedics (one from fire one from EMS) said that they needed the original for it to be legal.


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## BossyCow (Sep 22, 2008)

Okay, this might be a silly question, but I just gotta ask it. If the family, hospice and everyone was in agreement that the woman was DNR, who called 911 and for what purpose?


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## Jon (Sep 22, 2008)

MissTrish,

Depends on local protocols. In PA, to be a valid field DNR, it must be on a state prehospital DNR form, and the patient can wear a state-approved DNR bracelet, etc.

Without the paperwork, we'd call command and discuss the situation with them.


Personally, based on the description you gave me, I'd be VERY worried about taking this patient and putting them into an ambulance. I'd spend time PRIOR to the transport discussing the case with everyone, and ensuring that I had a valid DNR, or that the family was aware that if she coded in the back of the rig, we'd be diverting to the closest hospital emergency department. If they wern't onboard with this... we'd be reconsidering the transport.

These transports are difficult, for everyone.



Beach - DNR doesn't mean Do Not TREAT.


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## MissTrishEMTB08 (Sep 22, 2008)

BossyCow said:


> Okay, this might be a silly question, but I just gotta ask it. If the family, hospice and everyone was in agreement that the woman was DNR, who called 911 and for what purpose?



No one called 911, I work for non-emergency transport. We were transporting from private residence to Hospice. The woman was bed confined, I found out very recently she was supposed to be on oxygen but when we asked family and the case worker, they said no, she isnt on oxygen. And as we are a BLS truck, we dont have a pulse ox.

We arent allowed to turn down transport, and we told the family if she coded we would have to work her because they couldnt find a DNR.

We also dont have a direct connect to the medical director, we would have had to gone through a supervisor via cell phone, and both of us are new so we didnt think about that.


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## marineman (Sep 22, 2008)

I've only ever worked on 911 rigs but in your first post you said the patient was cyanotic, it doesn't take a pulse ox to figure out the pt requires O2. Again I don't know how it works on non-emergent transport rigs if the family says no to O2 if you can't give it but regardless of a DNR as long as there are signs of life you must do any interventions you would normally do.

As for the DNR I'd go with Rid, go through whatever channels you have to in order to get med control to make a decision. This is a common issue brought up in class because ethics/morals and the law are on opposite sides of the fence. The easiest way to determine the appropriate course of action is if there are legal implications make someone higher on the chain make the call in order to protect yourself.


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## JPINFV (Sep 22, 2008)

marineman said:


> I've only ever worked on 911 rigs but in your first post you said the patient was cyanotic, it doesn't take a pulse ox to figure out the pt requires O2. Again I don't know how it works on non-emergent transport rigs if the family says no to O2 if you can't give it but regardless of a DNR as long as there are signs of life you must do any interventions you would normally do.



Every DNR I've seen has explicitly mentioned that supplemental oxygen is considered a part of comfort care. As such, an EMT-B should be able to convince a family member to agree with basic supplemental oxygen administration. It's one thing to agree to terminate life sustaining treatments. It's another thing to ask to terminate comfort measures.


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## marineman (Sep 22, 2008)

That's pretty much what I was thinking but didn't know if it was different based on the 911 vs. non-emergent transfer. Especially since they don't have a direct connection to medical control I thought maybe they were at the mercy of the caregiver they were receiving the patient from.


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## JPINFV (Sep 22, 2008)

I would actually expect IFT providers to be more familiar with DNRs and DNR procedures than pure emergency providers since the IFT providers would encounter DNRs much more often for much milder complaints. If you're (generic "you") in a situation where you are going to be constantly transporting patients with DNRs, then you should know the protocol backwards and forwards. You will see them and see them often and the last thing you want to be thinking about is if you understand what you're supposed to do as the hospital RT changes your patient from BiPAP to a venturi mask so you can transport him to home hospice.


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## traumateam1 (Sep 23, 2008)

Well, I would work the patient. If there is no present DNR Order in front of me than I have no choice to work it. Says protocol. 


> Here's an idea.. .think. Get that old doctor of yours a chance to work. Call medical control or even the patients hospice physician and get a verbal DNR. Give a brief history of the patient and most ER physicians, medical control will authorize a DNR. A verbal order is enough until the physician can order one, a living will in some states can be the same as a DNR with specific conditions of what the patient wants done and not done. Hence the Living Will.


Critical Thinking. Call your MD and tell them the situation, give them a hx and p/ts current status. Chances are you will get a verbal DNR.
However until that happens, or I see a DNR I would work the patient.


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## EMTCop86 (Sep 23, 2008)

Why was she being transported from her home back to hospice? I live in CA and my grandpa was put on hospice. I thought hospice was a program for people to go through so they can die at home. We had nurses come every few hours but there was never talk of transport to a hospital or hospice. My grandfather died at home like he wanted too. Can someone please clarify for me? Is it different in different states?


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## MissTrishEMTB08 (Sep 23, 2008)

Because not all Hospice programs are home hospice programs. She was going to a hopsice house, mainly because her husband said he couldnt deal with having her home anymore. This particular hospice is really, really nice. The beds are big, colorful, and soft. The room is really happy looking with a big flat screen TV but more importantly it doesnt look like a nursing home or hospital, it looks like the patient is in their own bedroom, kinda. Its really beautiful and nice.

If I had to go somewhere to die, it would be scary regardless, but this place would make it a lot easier because it is so comfortable and homey. And the staff is an amazing group of nurses, LPNs and aides. They are very very compassionate, caring, kind and gentle.


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## Jon (Sep 23, 2008)

Some places offer hospice care in the home, some in some from of inpatient facility.

That said... From what you've told us, as a Monday-Morning quarterback, I think that you should have stopped when you first saw the patient and determined that she wasn't stable. (Remember... O2 is good, blue is bad?), and elevated the decision on transport and DNR up the food chain. Get ahold of dispatch/supervisor and get in touch with OLMC. Document, Document, Document. Perhaps call the hospice program and present the case to a doc there... get their thoughts/input before you take someone who seems to be breathing funny and take a BLS ride through town.


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## Vizior (Sep 23, 2008)

Remember... you're still an ambulance, even if you're "just doing transports."  Don't start transport with a patient who doesn't have a DNR who is supposed to have one.  Explain that if the patient does not have a copy of the DNR for you, and they have a medical condition that needs to be immediately treated, they're going to the hospital.  

Further consider what kind of obligations you have as a provider when you show up to a patient's residence, and have a patient who can't refuse treatment and transport from you, and what is in the best interest of the patient, and will also cover you from legal action.


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## MissTrishEMTB08 (Sep 23, 2008)

Jon said:


> Some places offer hospice care in the home, some in some from of inpatient facility.
> 
> That said... From what you've told us, as a Monday-Morning quarterback, I think that you should have stopped when you first saw the patient and determined that she wasn't stable. (Remember... O2 is good, blue is bad?), and elevated the decision on transport and DNR up the food chain. Get ahold of dispatch/supervisor and get in touch with OLMC. Document, Document, Document. Perhaps call the hospice program and present the case to a doc there... get their thoughts/input before you take someone who seems to be breathing funny and take a BLS ride through town.



The Hospice CLEARED her for transport. Thats what Ive been saying. The hospice case worker (who is an RN) said she was ok to be transported, it wasnt until we got there that they said nooo she shouldnt have been. The case worker was aware of the fact there was no DNR available. 

We are not allowed to refuse transport. Period. Even if we feel the patient is a bit more critical, the best we can do is call and request to go code 3.

I understand we are still an ambulance. If I was in back it would have been much different, she would have gotten CPR all the way to the nearest hospital. We informed the family she would have to be worked, but my partner chose not to work her. 

I was simply starting a topic for discussion not to be nit picked. Im extremely new to both being an EMT and the company, cut me some slack.

Edit: Maybe we should have been clued in to the fact the hospice case worker was an idiot when he couldnt take a blood pressure.

From 88/42 to 110/86 in 10 minutes? Seems a little fishy. Both me and my partner got nearly the exact same, give or take 2 mmHg with out informing the other of our readings. And yeah, I checked both arms.

Edited Again: Also, the hospice was super cool, they gave us free slushies!


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## JPINFV (Sep 23, 2008)

MissTrishEMTB08 said:


> Edit: Maybe we should have been clued in to the fact the hospice case worker was an idiot when he couldnt take a blood pressure.



I'll clue you in now then. Hospice case workers are idiots until proven otherwise. I don't think I've ever gotten a properly filled out DNR from one (and, no, that "Physician Signature" line is not optional. No, "Jane Doe, RN" is not a physician's signature) and I expect, out of ANY and ALL health care workers, that hospice workers would know DNR rules and regulations like the back of their hand. When part of your job consists of setting up transports for hospice patients, I don't think it's asking much to become an expert in the transport regulations (-especially- if it's one set of rules for every ambulance service operating in that area/county).


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## traumateam1 (Sep 23, 2008)

MissTrishEMTB08 said:
			
		

> I was simply starting a topic for discussion not to be nit picked. Im extremely new to both being an EMT and the company, cut me some slack.


Some people come off a little hard or strong on here. Trust me, I've been nit picked to death on here. So try not to take it too personally.


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## TheAfterAffect (Sep 23, 2008)

As for Refusing Transport, Ive worked for two different Transport companies and it was the same at both. If the Patient is unstable, You DO NOT transport. You can refuse transport all you want, You call up your dispatcher away from the family and give them the low down that the PT is severely unstable and most likely the family is making this a morgue run. 

Rather then risk being sued by the family (Espescially since there was no present DNR) your company will most likely tell you to either wait there till conditions improve, or a DNR is presented, Or to sca-daddle out of there and let the family deal with it.


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## EMTCop86 (Sep 24, 2008)

JPINFV said:


> I'll clue you in now then. Hospice case workers are idiots until proven otherwise.


 
I can attest to that fact. When my grandfather was on hospice at home we had nurses come every few hours. We had one really good nurse and one really bad one. Towards the "end" we had a nurse with us throughout the night. This particular person kept waking up my grandmother saying and I quote "Oh god I think he is going to die any minute now." We were pretty sleep deprived at this point and all rush up and gather around the bed and then nothing. She did this about 3 or 4 times until we had had enough and told her to leave. He ended up not dying for a few more days. I don't know what her problem was, maybe she was new, who knows...


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## el Murpharino (Sep 24, 2008)

Being new at EMS and at this company, this should serve as a valuable learning experience.  Ask your supervisors for clarification on the SOP's in these circumstances, and next time there won't be any confusion.  There are alot of grey areas in EMS; with experience you will develop a knack for these types of situations and how to handle them.  Don't beat yourself up over it, but do learn from it.


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