# At home to die.



## Scout (May 22, 2009)

You get called to a house. Pt was discharged form hospital to pass away in peace, full DNR etc. Breathing gets a bit difficult and you are called. You decide based on the pt condition that a bit of o2 would be of benefit. Pt does not want to go back to hospital and expects to die that night.

Now would you say thanks very much, sign the paper refusing transport, thats done pack up go home.

Would you leave enough o2 for her to last the night and then come back and collect the cylinder in the morning?

Or...


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## firecoins (May 22, 2009)

Scout said:


> Would you leave enough o2 for her to last the night and then come back and collect the cylinder in the morning?



why in the world would you do that?  Your treatment stops with a RMA.  

Patient is dying and wants to die at home.  They have competed all the paperwork.  Respect their wishes and move on.


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## Afflixion (May 22, 2009)

The Pts hospice nurse should have taken care of all comfort measures. So long as the Pt is CAO enough to make decisions form her/himself you get the PT to sign refusal if they truly do not want to go. If they are not get the person with the medical POA to sign. *Though make sure that the DNR order is filled out properly, signed in all the right places by the corresponding people and that it is an out of hospital DNR.*


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## Sasha (May 22, 2009)

firecoins said:


> why in the world would you do that?  Your treatment stops with a RMA.
> 
> Patient is dying and wants to die at home.  They have competed all the paperwork.  Respect their wishes and move on.



DNR is not DNT. 

A little O2 by NC will not stop their death, but ease their passing. That's why they still have O2 in room at inpatient hospices. 

I'd call a super and see what they say about it.


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## Ridryder911 (May 22, 2009)

Alike others described my service as well does not leave oxygen at patients home. As well, patients do not really always exactly know when they are going to die. 

As a Supervisor, I would obtain the Hospice case manager number and notify her that she has a patient she needs to schedule a visit to. Ensure that the patient family or NOK that is to be notified has been called and make sure the patient is stable enough to make a rationale and justified decision of refusing transport and care. There is not much for the EMS crew to do. 

If they need a concentrator or oxygen bottle then I would relay that information to the case manager as well. The Hospice has contracts with medical suppliers to ensure the patients needs. 

R/r 911


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## DrankTheKoolaid (May 22, 2009)

*re*

Agree with rid for sure as that's our policy.


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## Aidey (May 22, 2009)

The only way I would leave the O2 is if the patient was Rxd it, and they called because the O2 was empty/malfunctioning etc and they needed some until they could get it sorted out. O2 is considered a drug, and needs to be prescribed. IMO you would be stepping outside your scope by leaving the O2 with the family because you would essentially be prescribing it.


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## vquintessence (May 22, 2009)

Interesting scenario Scout.

So most of you wouldn't leave a D tank cos it's "not by the book"?  No qualms with anybody if specific policy prohibits or a supervisor denies, but otherwise... why wouldn't you?  Interestingly enough experienced this situation last winter.  Poor woman in late 30's at home withering away from breast ca that had metastasized at a horrifying rate.  Mom in complete, utter denial.

Mum calls 911 resp distress, just like OP.  Yadda, yadda, wants a quick fix but without any transport.  hospice nurse not present but gets on her way for moral support for Mum.  Pt has been medicated by Mum as prescribed by RN.

END of story:  We were on scene about *forty minutes providing whatever pitiful penance of compassion we could offer the Mom as strangers* as we waited for hospice RN to arrive.  The mother was reassured that she was doing everything possible in caring for her daughter.  *We left our D tank as a symbolic gesture of empowerment for the mother, hopefully giving more faith that she has allowed her daughter to pass in peace.*

Scouts scenario extends far beyond the realm of caring for the pt with the DNR.  rephrase:  If 911 is contacted for a HOSPICE pt, then chances are good there is more than one pt on scene.


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## VentMedic (May 22, 2009)

If this patient is in Hospice with a comfort care status, the O2 may already have been discussed. It is usually better to ease discomfort pharmacologically with meds other than O2. Sometimes even a little nebulized morphine or fentanyl will work much better than O2. Some get too focused on using the O2 and forget what else can be given. This is not necessarily a respiratory issue and unless you can fix a failing heart, all the O2 you have will be of little use.   

The Hospice RN should be contacted while you are on scene. Between the RN, Case Manager and Hospice doctor they will figure out what the patient needs. 

Leaving your own tank is a liability even though it is a nice gesture. You may also have to figure out how you are going to show how you continued to treat without remaining on scene as well as getting a refusal of transport signed.


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## trevor1189 (May 22, 2009)

Ideal World: Leaving the patient with an oxygen tank to ease their dying process, in my opinion, is a nice gesture and if it helps them, but all means.

Real World: Major liabiliy, for equipment, and patient. What if the tank is damaged? What if the patient runs out of O2, you are not their to provide care and cannot be sure the O2 is flowing at the proper rate. Short of the Rx from a doctor and a EMS supervisor to "loan" the equipment, as well as a waiver from the patient or next of kin, I wouldn't do it.

It really is a shame, but in today's would you have to think about yourself first. CYA.


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## VentMedic (May 22, 2009)

trevor1189 said:


> Real World: Major liabiliy, for equipment, and patient. What if the tank is damaged? What if the patient runs out of O2, you are not their to provide care and cannot be sure the O2 is flowing at the proper rate. Short of the Rx from a doctor and a EMS supervisor to "loan" the equipment, as well as a waiver from the patient or next of kin, I wouldn't do it.
> 
> It really is a shame, but in today's would you have to think about yourself first. CYA.


 
Believe it or not a comfort care patient will not always get O2 while in the hospital. Pulse ox checks are also a big no-no. The idea is not to prolong life but to make them comfortable. As I mentioned before, when cardiac output and other physiological processes start to fail, no amount of O2 is going to alleviate that type of suffering for very long. These patients may initially be only on a very low dose of comfort medications which CAN be increased if the family follows the instructions given to them by notifying their nurse. Some families, as are some healthcare providers, are apprehensive about giving pain medicine due to all the stuff they have seen on TV. As well, people don't always die as glamorously as they do on TV. Their last few hours or even days can strain even the most seasoned healthcare providers. Often it is the families who want the patient transported to the hospital because they can not handle the situation any longer. Some of these patients may end up dying alone in a hospital or NH room because their families have a rougher time dealing with death than the paitents.

It is also up to the hospice RNs to help the families deal with death and they end up being more time consuming than the patient. Many families have past issues that have not been resolved and get a twinge of guilt in the last hours that they didn't do more for their loved one. Thus they try to become a model caregiver during the last few hours but end up becoming a mess or making a mess in the process. 

My question to the OP, was it the patient or the family that called 911?


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## trevor1189 (May 22, 2009)

I didn't say O2 would definitely help, I just said if it helped it's a shame as EMS, we can't leave the patient with O2 to ease the process.

My grandfather died from Alzheimer's and I remember what it did to my family. I was young but I remember my mom and other family members trying to keep him comfortable in his last days. It took everything they had.

One thing I remember is everyone knew he was going to die soon, and were saying their final goodbyes. Shortly after his last sibling arrived to say goodbye he passed away. It was almost as if he was waiting.

I am very much a science person, but that almost seemed like he was able to stay alive to make peace with everyone.


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## firecoins (May 23, 2009)

Sasha said:


> DNR is not DNT.



A refusal medical care means you do not provide oxygen.  

As already mentioned leaving o2 at home is a liability. And if the o2 bottle becomes empty will you return to refill it?     Will you be standing by at their hourse?


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## Sasha (May 23, 2009)

A DNR is a refusal of medical care if and when the patient goes into arrest. No where in the scenario given did it say the patient refused medical treatment. Transport, yes, treatment, no.


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## VentMedic (May 23, 2009)

Sasha said:


> A DNR is a refusal of medical care if and when the patient goes into arrest. No where in the scenario given did it say the patient refused medical treatment. Transport, yes, treatment, no.


 
I did make an "assumption" by the statement of being released home to die that the patient was under some type of hospice program or some type of care directed by a doctor where death is imminent.

If the patient is on hospice care, there will be a plan of care in place as well as a contract for which interventions the patient may need or will be able to receive under hospice.  

If hospice is not part of the decision making for additional treatment, the patient may lose his/her benefits.  Getting requalified for home hospice may be more difficult and the patient could end up stuck in a multi person room to die at a hospital or NH.  

However, a patient, by their own decision  and preferrabley not the family's, can consent to medical treatment.


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## boingo (May 23, 2009)

I've seen this situation on several occasions.  I am more than happy to make the patient as comfortable as possible, without sticking them with needles or transporting.  Hospice is the best program ever.  They are great at what they do, however there are times when a patient is dying at home and the hospice nurse isn't immediately available.  They usually have liquid morphine and ativan at the house, which I'm more than happy to assist them with, or if that isn't an option, some intranasal fentanyl for pain management.  Its a treat and release, there is no book or protocol for it, it is just humane.  I do consult with medical control, explain the situation to family, and do what little I can to help.


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## firecoins (May 23, 2009)

Sasha said:


> A DNR is a refusal of medical care if and when the patient goes into arrest. No where in the scenario given did it say the patient refused medical treatment. Transport, yes, treatment, no.



when the RMA is signed I can not stay and continue to provide treatment ad nauseum.  We dont provide long term care. If the patient is in need oxygen, they get transported. We don't have the resources to provide hospice care.  I can not leave my equipment behind.  Any situation like that in the OP will have Hospice care with oxygen anyway.


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## gicts (May 23, 2009)

ahh the clash of world wide diverse cultures on the internet.  I'm sure in general some small towns or non busy departments would gladly allow the temporary use of an oxygen cylinder and render common courtesy aid as needed. And on the flip side in general, I'm sure busy cities that are swamped with runs would get a signature and get out ASAP h34r: Though not uncommon, one does wonder why EMS was called in this situation to begin with.


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## Sasha (May 23, 2009)

gicts said:


> ahh the clash of world wide diverse cultures on the internet.  I'm sure in general some small towns or non busy departments would gladly allow the temporary use of an oxygen cylinder and render common courtesy aid as needed. And on the flip side in general, I'm sure busy cities that are swamped with runs would get a signature and get out ASAP h34r: Though not uncommon, one does wonder why EMS was called in this situation to begin with.



 they call because they dont know what else to do. its easy for everyone to say they will follow their dying family members wish to a t. however considering the massive emotional toll this must take i dont think that any one can judge these people who call for a dnr family member until they have been in that position. its easy to say under no stress that you wouldnt call 911 but how do we know how we will react when the time comes? who do you call when you dont know what to do and are compelled to try and ease their suffering?


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## EDAC (May 23, 2009)

I went through this with my father-n-law 2 years ago, he had a DNR on file at the care facility where he was. He had suffered a massive stroke and was a shell of the man he had been. I was with him the day he passed away, he just closed his eyes and fell over. The ambulance was called and the paramedics were there within minutes. He had a weak pulse and very shallow breathing, they asked me if I wanted them to start treatment, when it is your family, that is the toughest question you will ever be asked. I said no he had requested when he began to slip away to leave him be. That is just what we did, his heart stopped, then he quit breathing. The ambulance left and we waited for the funeral home to pick him up. I even to this day will ask myself if I made the right decision, but it really was not my decision to make. I am glad my wife was not there at that moment, how hard would it have been for her to say let my dad die. Even if he were revived he would have still have been unable to feed, dress himself, or use the restroom with out help. So it was best for him to not have to continue to live that way. I hope I never have to go through anything like that again with a loved one, it is a very hard thing to do.


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