# Please Help



## hangten901 (Feb 5, 2008)

Hi,
I am an EMT from northern indiana and I was hoping someone could help me out. I am a senior in high school and am currently trying to complete my senior exit project on the right to die. I need to find several medical professionals opinions on the subject, preferablly a paramedic or experienced EMT's as well. I was hoping to find opinions from those that have dealt with terminally ill patients, as well as depressed or other types of people that would be related to the subject, however all opinons are welcome. If I could get some people to post their replies to the following questions that would be great: Do you think a person or patient has a "right to die" or right to assisted suicide?
If yes, to what extent should this right be stretched: should any one have the right? or should it be reserved to terminally ill patients in pain? Also should it be banned from any group of people? (such as depressed or otherwise healthy people)
If no, do you feel that this is do to a moral issue? Or also do you think that it would be a possibility in the future, for instance if our society is not ready for it now? 

Thanks alot and I hope to use this for my senior exit project.
Steve


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## hangten901 (Feb 5, 2008)

Hi,
I am an EMT from northern indiana and I was hoping someone could help me out. I am a senior in high school and am currently trying to complete my senior exit project on the right to die. I need to find several medical professionals opinions on the subject, preferablly a paramedic or experienced EMT's as well. I was hoping to find opinions from those that have dealt with terminally ill patients, as well as depressed or other types of people that would be related to the subject, however all opinons are welcome. If I could get some people to post their replies to the following questions that would be great: Do you think a person or patient has a "right to die" or right to assisted suicide?
If yes, to what extent should this right be stretched: should any one have the right? or should it be reserved to terminally ill patients in pain? Also should it be banned from any group of people? (such as depressed or otherwise healthy people)
If no, do you feel that this is do to a moral issue? Or also do you think that it would be a possibility in the future, for instance if our society is not ready for it now? 

Thanks alot and I hope to use this for my senior exit project.
Steve


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## MikeRi24 (Feb 5, 2008)

Well, I am still in the learning stages of being an EMT myself, but my personal opinion is this:

I do NOT believe that you should concentrate this towards any one group of people. I know I just contradicted what I said, but one thing that I have already learned is that no matter what the situation, no matter what color, gender, age, shape, whatever, the patient is, you have to treat them all the same and do everything you can for them. In New York where I'm from, anything less than that is considered negligence and could also be considered abandonment and a bunch of other stuff that you could lose you license for and get in really deep trouble. From the legal point of view, unless a person has a DNR *PRESENT*, you have to treat them accordingly. I'm not sure about other states, but in NY that is the law. 

Looking at this from another angle, if a person is badly injured in a MVC, and they are in severe pain, and they say "oh this is horrible just let me die" are you really going to do that? Aside from the fact that you can't, you have to remember that in the EMS field, you are dealing with people in their most vulnerable moments, and a lot of times they are out of it and not saying stuff they really mean. Rather than telling the person in extreme pain "ok, you want to die? we'll let you die not a problem" you should be telling them "hey, I know your [insert source of pain] really really hurts right now, but we're going to take good care of you and get you back into shape" 

As an EMS provider, it is not your job to play God. It's not the ED doctors' job to play God, its not the ED nurses' job to play God, its not ANYONES job to play God. You as an EMS provider have the responsibility to treat and care for every patient to the best of your ability. You have to have a love for the job and a passion for helping people (because none of us are here for the money), and the day you lose that drive and passion, is the day where you should leave EMS.


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## Ridryder911 (Feb 5, 2008)

There is a fine line between suicide and allowing someone to have .."_death with dignity"_. 

Personally, I am NOT in favor of assisting or aiding in the death of someone. That is NOT what I am in healthcare for. With that said, I am in all in favor of allowing nature to take its own course. It is all dependent upon the pre-wishes of the patient as well as the understanding of a reasonable man. That being most do not want extensive pain and suffering, as prolonged vegetative state. 

Like medical ethics, nothing is black and white. Personally, I have no problem of a patient being induced into a coma state from analgesics that has a 99% total body surface burn.. if the patient so happens to quit breathing, so be it. Again, letting nature takes its own course . The quite opposite of allowing someone in a vegetative state suffer from pain of dehydration and hunger due to lack of water and food. Again, it is a fine line. I guess, it is all upon what is definition of life or living? 

Unfortunately, sometimes we have to play God and make the determination of whom gets to live and whom get to die. I ask him for His guidance on each of those decisions and go from there. Again, this is why we get paid the "BIG BUCKS"! 

R/r 911


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## JPINFV (Feb 5, 2008)

I think that questions like this is intrinsically a question of personal ethics and values. Where does a patient's life and a patient's ability to control it lay? Who can control what medicals decisions and when, especially if the patient is unable to do so due to coma or other medical problems? How big of a difference is there between "pulling the plug" on a coma patient vs honoring a more healthy patient's wishes? At what point is a condition considered permanent enough, disabling enough, or painful enough to warrant a competent patient to be able to 'pull their own plug' so to speak?


At the EMT-Basic level, these aren't questions that are even put up to be considered. It's much more of "here's the rules, you will follow them and not ask any questions."

Personally, I do believe that a competent person with a serious, permanent condition should have a right to die. This should be between the patient and his/her primary medical physician and not left up to mid-level providers (nurse practitioners and physician assistants) and definitely not left up to EMS providers. There is a significant difference between honoring someone's wishes to not be treated (patients with Do No Resuscitate orders or who request no treatment) and taking a proactive role in ending a life. 

It should be limited to patients with incurable life altering [either through disability or pain] diseases who are able to comprehend their decisions and display sound reasoning [free from psychiatric illnesses that would affect decision making capacity. There's a difference between a phobia and depression, for example].


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## Meursault (Feb 5, 2008)

I don't really want to get dragged into this, but I find it hard to resist. "Internet debating is like the Special Olympics: even if you win, you're still retarded."
(not mine, but rather apt.) More importantly, this is a moot point in prehospital care.

A couple points: 
The right to refuse treatment is not a "right to die".
There's a clear distinction, for example, between withdrawing life support from a braindead patient and writing another patient for a lethal dose of barbiturates. In the first, an intervention that brings no benefit to the patient (futile care) is discontinued. DNR orders also fall in this category. In the second, a medical professional directly intervenes to bring about the death of a patient in his or her care. 

JPINFV: Isn't a desire to die an indication of mental illness? If not, what are the criteria for separating patients who want to die but are considered healthy from patients who want to die as a consequence of clinical depression? Is it, as you suggested, based on whether the evaluator thinks that it is reasonable for the patient to want to die, i.e. considers his or her patient's life worthless? There's a reason these judgments are not in our hands.

There are more complex issues here, and more substantial arguments on both sides. I'm sure anyone who's interested will bring them up.


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## VentMedic (Feb 5, 2008)

In the U.S. almost every hospital now asks a patient upon their admission if they have advanced directives no matter how minor the illness or injury is.  If the person is unclear there are people to help them decide if the patient requests.  When a person is diagnosed with a potentially terminal or incapacitating illness, there are people to help a patient through the DPOA or medical surrogate process. 

Jack Kevorkian had the right idea but the wrong screening process and was very ill advised in the public relations department.   Hospitals have been doing end of life in the form of comfort care, hospice and withdrawing life support for decades.  The patient does not have to be brain dead to withdraw life support.

When a patient is admitted to the hospital, if their condition looks like it could advance to critical, our physicians will have a frank discussion with the patient, first privately and then with family members if the patient allows.  It is good for the family to hear from the patient what he/she wishes if things take a turn for the worst.  The patient is allowed to control their destiny to a certain extent.  These patients are usually end stage in COPD, renal disease, cancer, AIDS, autoimmune diseases, cystic fibrosis, liver disease, cardiomyopathy or any other disease that has progressed to where quality of life and life itself is limited.   

If the patient is going to need intubating with life support, the physician will discuss all the potential outcomes with the patient from the very best to the grim. The physician will ask the patient what their thoughts are if their condition does not improve.  Many patients that have terminal illnesses have already thought about this and are usually clear about their wishes.  There are also patients who are steadfast about not being intubated but can be talked into it for some procedures or medical conditions that may be reversed such as PNA or CHF with a promise from the physician that if the course doesn't go as planned, life support will be withdrawn. 

If the patient is not intubated and their condition is deteriorating they will be offered comfort care at the hospital and home/facility hospice.  The decision will hopefully be made by the patient and/or family with the assistance of a physician and nurse who specialize in this area of medicine. 

There are also times when things have happened too fast for the patient to get their end of life decisions in order and the family is not ready to make that decision.  The physician may then take that decision to the ethics board at the hospital and have them make the decision. 

People who are institutionalized for mental illness may have a DPOA or conservator appointed to them to make medical decisions.  If the person has a poor prognosis from a suicide attempt, the family and ethics committee will meet to decide how far the medical care will continue. 

For young trauma patients we will do everything we can in the hospital but there may come a time when modern medicine can not help even in the best of hospitals.  There have been times when a hospital will continue as long as the family keeps hoping and sometimes the patient actually will start to become so infected and/or bodily deteriorating that the odor will keep the family from entering the room.  

As a Respiratory Therapist I have assisted with end of life procedures in the hospital under the orders of a physician many times.  I have "pulled the plug" on every age from infants, kids, young adults and the elderly.  A chaplain from the hospital or the family's choice is usually present.  The patient is put on a sedation drip by the RN. No paralytics are used.  I then pull the ETT and shut off the ventilator.  It is not always smooth for the patient may gasp and linger for hours after the tube is removed.  The sedation will be titrated in attempts to make the patient comfortable.  Sometimes the family panics at the first gasp and begs me to put the tube back in.  I am always thankful for the chaplain's presence at that time because they know the right words to comfort the family.   I have not lost any sleep over pulling someone's ETT for end of life under the directives of my hospital and physicians.   Usually everyone on the medical team is on the same page when end of life measures are initiated.

As a young Paramedic I saw things very differently. Every patient near death or in a code situation who didn't have a clear DNR with DNI order that I could get to the hospital with a heart beat was a "save".  I didn't always understand when the ED physician would stop the code or not be aggressive with some of the patients. Now, after also working several years in the hospitals, I definitely understand what quality of life is.  I think that my work experience in Pediatrics gave me the most insight on end of life or more importantly quality of life from children with terminal illnesses who openly discussed their wishes with full knowledge and wisdom way beyond their years.

Now for clarification; DNR does not mean do not treat.  The patient has the right to be fully informed about their care.  They can and should be treated for any medical condition that is considered reversible or treatable.


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## hangten901 (Feb 5, 2008)

Thank you very much, I really appreciate the quick replies. I will definitely use your professional opinons/views on my project.


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## hangten901 (Feb 5, 2008)

Wow I am impressed with the quick replies. Thank you guys very much for helping me out, this will really help my project as I am incorporating each of your opinions into it. Thanks again


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## JPINFV (Feb 5, 2008)

MrConspiracy said:


> A couple points:
> The right to refuse treatment is not a "right to die".
> There's a clear distinction, for example, between withdrawing life support from a braindead patient and writing another patient for a lethal dose of barbiturates. In the first, an intervention that brings no benefit to the patient (futile care) is discontinued. DNR orders also fall in this category. In the second, a medical professional directly intervenes to bring about the death of a patient in his or her care.


What about withholding life support from a newly critical patient under the patient's request? I do agree, though, that the right to consent to treatment and the ability to request life ending treatment are two different things, but I think that the line between the two is very thin.


> JPINFV: Isn't a desire to die an indication of mental illness? If not, what are the criteria for separating patients who want to die but are considered healthy from patients who want to die as a consequence of clinical depression? Is it, as you suggested, based on whether the evaluator thinks that it is reasonable for the patient to want to die, i.e. considers his or her patient's life worthless? There's a reason these judgments are not in our hands.


I don't think that a desire to die is, in and of itself, a mental illness. Certainly, someone who is healthy and not under any significant emotional stress [how many people have expressed a desire to die after a loved one has passed? Certainly they shouldn't be eligable for physician assisted suicide, but I'd argue that they are not mentally ill either] that expresses this desire would have to be evaluated for a mental illness.

I think that the physician evaluating a patient requesting an assisted suicide would be evaluated in a similar fashion as DNR patients. Instead of a, "Are there any conditions that we don't know about and does the patient understand the ramifications of a DNR order?" it would be more of a, "Does the patient understand what he/she is requesting? Is the nature of this disease/disorder having significant negitive impact to the patient's quality of life or causing great pain? Is the condition incurable?" You're right, the final decision should not be ours as a medical provider, and espeically as EMS providers. It, as with DNR orders [which some systems can respect verbal requests from the patient and immedate family. Source available on request] should ultimately be in the hands of the patient.


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## ffemt8978 (Feb 5, 2008)

Duplicate threads merged.


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## Ridryder911 (Feb 5, 2008)

MikeRi24 said:


> As an EMS provider, it is not your job to play God. It's not the ED doctors' job to play God, its not the ED nurses' job to play God, its not ANYONES job to play God. You as an EMS provider have the responsibility to treat and care for every patient to the best of your ability. You have to have a love for the job and a passion for helping people (because none of us are here for the money), and the day you lose that drive and passion, is the day where you should leave EMS.



Obviously, you have never worked an MCI or worked daily on end stage multiple organ failure severe patients. It would be nice to be able to make such blanket statements.. but it is time to wake up and smell the coffee. The world is not that easy and there is not a rainbow at the end of the day. I *definitely* know I am not God, just an instrument. There is a time someone has to make such determination. Many of the times, it will be you. 

Ever heard of field termination of codes? A very common occurrence to stop the code after you started. Even now there is more scrutiny of .."if and when".. to start is now becoming a hot issue, that we probably see change in the new CPR standards next year. So when do you stop or better yet; when do you start? Seriously. Do you start resuscitation efforts on that aborted fetus found in the bathroom that is <22 weeks old? For what reason? They will be terminally blind, deaf, and barely brain function. Even in some of the emergency medical communities that is a debatable scenario and some will tell you not to (refer to AHA/AAP NRP). Again, EMS has little exposure to real medicine. 

It is not being pompous it business. It's someone job to have to make the determination to "pull the plug". Do you actually think everyone has a nice timely death? Reasons, that I do NOT work traumatic arrest. Period. Very few in EMS do. The reason, it is not been proven to work. Again, someone had to make that determination. 

We need to stand back and look at the whole picture. Quality of life versus just being alive. Fortunately, patients are being educated and more informed about the horrible situations of long term illnesses and the long term treatments associated with them. I know Vent can attest taking care of such patients. Some patients may survive, and there are those that there is nothing more than a machine with a body attached.  That is why _ Living Wills and DNR's_ are so important and should be honored. 

Again, there is NO right or wrong answer. This is why ethics is so debatable. Heck, I can even debate myself. One can have multiple feelings more than way about a subject.. there is no black or white answer. 

R/r 911


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## BossyCow (Feb 6, 2008)

*None of us get out of here alive!*

Hey, we're mortal. We all die eventually! 

The issue as I see it is when and how. Currently medicine prolongs our life and 'manages' disease to the point where we survive past the point where that disease would have killed us in another century. 

Personally, I'm comfortable with my own mortality. I've buried both parents, a brother and a child. I understand that our life span is limited. 

Too many patients, and we've all seen them, are willing to prolong their lives way past their ability to enjoy that life. I remember a pt who had Kidney Failure, Bladder Cancer, CHF and Diabetes. She had full code status. We brought her in several times, each time assuming it was going to be the last. 

But, it's a personal choice. We all decide whether to get that mole checked out, do regular health screens or to ignore obvious symptoms. That's where it starts. 

As far as assisted suicide, I do not presume to judge for another human being, what could drive them towards such an act and to determine for them that it is not a correct course for them. I do not believe that the process or the mechanism should be financed or provided by any government agency. But neither should it be criminalized. 

I say, let us all make up our minds on this, for ourselves, by ourselves and before we need it desperately. Make those desires known in writing for your family and friends.


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## JPINFV (Feb 6, 2008)

On a lighter note, it would solve the Solyent Green shortage.


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## MikeRi24 (Feb 6, 2008)

Ridryder911 said:


> Obviously, you have never worked an MCI or worked daily on end stage multiple organ failure severe patients. It would be nice to be able to make such blanket statements.. but it is time to wake up and smell the coffee. The world is not that easy and there is not a rainbow at the end of the day. I *definitely* know I am not God, just an instrument. There is a time someone has to make such determination. Many of the times, it will be you.
> 
> Ever heard of field termination of codes? A very common occurrence to stop the code after you started. Even now there is more scrutiny of .."if and when".. to start is now becoming a hot issue, that we probably see change in the new CPR standards next year. So when do you stop or better yet; when do you start? Seriously. Do you start resuscitation efforts on that aborted fetus found in the bathroom that is <22 weeks old? For what reason? They will be terminally blind, deaf, and barely brain function. Even in some of the emergency medical communities that is a debatable scenario and some will tell you not to (refer to AHA/AAP NRP). Again, EMS has little exposure to real medicine.
> 
> ...



you're right, I haven't seen a lot of this stuff, but what I am being taught right now, is that you cannot deny a patient care. you have to do everything in line with the protocols, no matter what. If need be, you may contact the Medical Director of our agency, and based on the situation and information they give you, you may be able to stop treatment or whatever else. However, that is not a decision that I as an EMT can make. The field termination of codes thing would apply here. I as an EMT am not able to make that decision. I am responsible for calling the medical director (who is always online) informing them of the situation and they will direct me in what to do. I am responsible for doing everything I can to keep that patient alive until they are in higher care. If I'm doing CPR on someone during a 25 minute transport, and 15 minutes into it, its clearly not getting anywhere and the person is not responding to ANYTHING, I can't say "this isnt working...stop" I have someone can call the medical director, and tell them whats going on (while I am still treating the pt) and they can say "stop and pronounce it." I think different states may vary on stuff like this, and I know in my state, it varies from county to county even. and you're right, there is no right or wrong answer.


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## JPINFV (Feb 6, 2008)

MikeRi24 said:


> but what I am being taught right now, is that you cannot deny a patient care. you have to do everything in line with the protocols, no matter what.



I hope that they've included talking about the patient's right to decline treatment for themselves (assuming, of course, that the patient is alert, oriented, and able to understand the ramifications of their decision).


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## Ridryder911 (Feb 6, 2008)

MikeRi24 said:


> you're right, I haven't seen a lot of this stuff, but what I am being taught right now, is that you cannot deny a patient care. you have to do everything in line with the protocols, no matter what. If need be, you may contact the Medical Director of our agency, and based on the situation and information they give you, you may be able to stop treatment or whatever else. However, that is not a decision that I as an EMT can make. The field termination of codes thing would apply here. I as an EMT am not able to make that decision. I am responsible for calling the medical director (who is always online) informing them of the situation and they will direct me in what to do. I am responsible for doing everything I can to keep that patient alive until they are in higher care. If I'm doing CPR on someone during a 25 minute transport, and 15 minutes into it, its clearly not getting anywhere and the person is not responding to ANYTHING, I can't say "this isnt working...stop" I have someone can call the medical director, and tell them whats going on (while I am still treating the pt) and they can say "stop and pronounce it." I think different states may vary on stuff like this, and I know in my state, it varies from county to county even. and you're right, there is no right or wrong answer.




Your right, one has to do what they are told to do or challenge and change the protocols. Remember, protocols should be only suggestions and guidelines. There is reason why basics have very strict guidelines. My point being is don't make blanket assumptions. Medicine is *much* different in real life, than in the classroom and television. As well, there are diverse protocols around the U.S. and not everyone does the same. Our protocols emphasis there should be a reason to work the person and perform resuscitation, not the opposite. Since codes have been proven to have very poor outcomes, there are us that weigh the chances of survival and what the potential outcome will be. Downtime, medical history, circumstances, etc. all that will make the difference.


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## MikeRi24 (Feb 6, 2008)

JPINFV said:


> I hope that they've included talking about the patient's right to decline treatment for themselves (assuming, of course, that the patient is alert, oriented, and able to understand the ramifications of their decision).



of course. In fact, theres a whole section on the PCR and a spot for the patient to sign should the decide to decline our services, and thats perfectly acceptable. If they are not alert and/or oriented, then we will treat them under implied consent, and if they are and deny treatment but clearly need it, than a police officer can take them into custody and release them to us to treat the patient.


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## pyroknight (Feb 6, 2008)

Do you think a person or patient has a "right to die" or right to assisted suicide?

These are two separate issues.  If by "right to die" you mean the right to decide not to have a life of suffering extended, then yes, I do believe patients have a right to die the way that they choose without having interventions forced upon them.  In the state EMS office, we work diligently to ensure that our regulations give patients the ability to choose how they want their end-of-life care administered.  Assisted suicide is another matter entirely and does not fall into the realm of EMS.​
If yes, to what extent should this right be stretched: should any one have the right? or should it be reserved to terminally ill patients in pain? Also should it be banned from any group of people? (such as depressed or otherwise healthy people)

While pain is certainly a major component in most patients desire to avoid prolonged suffering, there are other factors which impact quality of life which should not be disregarded.  Healthy individuals with mental health issues should be treated for their mental health issues and usually are not considered competent to make decisions regarding their health care, whether they be measures to prolong life or not.  It is unfortunate that the mental health resources in this country have been greatly eroded over the last several decades to the point that it is now nearly impossible for many individuals to receive prolonged inpatient care.  While many individuals in times past were probably confined to facilities unnecessarily, I do not believe one could competently argue that there are numerous individuals who should have NEVER been released into the general public who are now forced to try to exist in our world when they would be safer and likely have a much better quality of life if they had remained institutionalized.​
If no, do you feel that this is do to a moral issue? Or also do you think that it would be a possibility in the future, for instance if our society is not ready for it now? 

I hope our society is never ready to condone terminating the lives of mentally ill but otherwise healthy individuals.  I hope that the treatment for mental illness will continue to improve and our understanding of the causes of mental illness will continue to increase to a point where we can provide better means of treating major depression, schizophrenia, and other causes of suicidal ideation to improve the quality of life for these individuals.​


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