# Hospice...



## btkspot89 (Apr 10, 2011)

I work for a Transport company and one of our contracts is Hospice provider. We were dispatched for a pick up coming from a residence going to a Inpatient  Hospice center. Patient is an 80 yr old male who is in the care of hospice for stage 4 cancer. Simple enough for my partner and I because generally they are routine and close enough to the hospice center. We arrive and greet the friendly pt who is fully alert and oriented. After stair-chairing him to our stretcher outside we make sure that we get a valid DNR (in this case MSNJ DNR) Simple load and go after. About 2 minutes in transit my EMT who was doing patient care told me the pt went unresponsive and had very shallow breathing. For hospice this was normal and we continued to transport to the hospice center (3 county's and several miles away) Shortly after my partner advised me that the patient had stopped breathing and had no pulse. He being a rather new member of the company was not sure about the protocol for a DNR hospice patient who had already been in transit to the hospice center. 
Needless to say this very rarely happens when a patient codes in the back of an ambulance has a DNR and is going for inpatient Hospice care. I did what I thought was right and contacted the dispatcher to call ALS. The dispatcher confirms that he dispatched them and that we should proceed to the nearest hospital. Shortly there after the operations manager (not an EMT) contacts me on the radio and tells me that she canceled medics and contacted the hospice center who advised us to keep transporting to their center (still 2 county's and miles away) Not to disobey my manager I comply turning off my lights and siren and start heading to the hospice center. Of course now we have a deceased patient in our ambulance crossing over several towns and 2 countys. Prior to our arrival at the hospice center my manager again contacts us and tells us to not cover up the patient and look like hes sleeping (Clearly a public relations thing). That got me slightly more agitated then I already was. We arrive there and the hospice nurse who arranged this whole thing said she was never in this situation before and did what she thought was right. I however was, about 5 months prior the same thing happened and I called medics who met us enroute and went with us to the nearest hospital where they would pronounce there (with no manager intervention) Anyone have any suggestions about how this could have gone better?


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## Veneficus (Apr 10, 2011)

I have been in a similar situation a couple of times. In all cases we followed the advanced directives of the patient, some want nothing, some want oxygen w/o intubation, etc. Even when they died in route we always continued to the destination. 

Really it is a waste of resources to call for an ALS intercept or to transport them to the ED in most cases. 

These patients are terminal, they understand it, they are prepared. They and their loved ones are better served by the hospice center than an ED. 

I have also been transporting hospice patients when they started to vomit, caugh uncontrolably, etc. Generally we simply called med control for permission to initiate care that would reduce or relieve their suffering. NG tubes, antiemetics, morphine, versed, that sort of thing and continued on to wherever we were taking them. 

Death is a normal part of life, it is not the enemy.


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## Sasha (Apr 10, 2011)

Why did you try to ignore the DNR?


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## usalsfyre (Apr 10, 2011)

It could have gone better by not contacting ALS, not attempting to divert and continuing to your destination. The patient was being transported to hospice to die. You had a valid DNR in hand. Why would you call an ALS unit and divert?

As for PR, get used to it, it's part of the game.


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## Sasha (Apr 10, 2011)

And its not for PR, you dont cover the patient for the family. They want to see peaceful, not a white sheet. For all they knew family could have been waiting at the front of the drop off

In Hopsice care the family is as much a pt as the actual patient.


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## HotelCo (Apr 10, 2011)

Call your medical control physician. Explain you have a hospice patient with a valid DNR, that's apneic and pulseless. Do what they tell you. 

As for managers... If it involves healthcare, I don't contact them. Go straight to the source (medical control).


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## mycrofft (Apr 10, 2011)

*Agree with HotelCo*

The only issue I see here is the question as to whether a death in one county was legally required to be declared by a MD local to the occurrance of death, and then registered by that County's medical examiner or coroner's office. 
Wonder if "EMSLAW" is still reading with us here? Calling "EMSLAW"


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## LucidResq (Apr 10, 2011)

That's what I'm wondering too. I've heard in some circumstances the legal thing to do would be to actually stop the rig and wait for the coroner. I'm not sure if that's true or not.


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## emtphoto (Apr 26, 2011)

*any body know the laws*

I am also concerned about the law in this issue. Dose anyone here know where to look for the rules on this subject? After all was said and done this could have gone very bad under other circumstances. public relations aside.


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## Akulahawk (Apr 26, 2011)

Your protocols/guidelines should have a section for DNR patients and destination decisions for them should a patient die during transport. In Sacramento, we're to continue to the pre-arranged destination. Santa Clara had some more specific guidelines for transport. We could continue to the destination, return to the origin, or divert to the closest ED... all as appropriate. 

So... know your County/System instructions for dealing with DNR patients and how to deal with body disposition should the patient die in your care, whether it be before or during transport. Code 3 transport for a DNR patient that has died is inappropriate and shouldn't be done unless you're required by some written policy to do so.


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## medicstudent101 (Apr 26, 2011)

If you felt uncomfortable with the situation or wasn't a 100% sure about your protocols, there's NOTHING wrong with requesting ALS. Each state, and county for that matter, has a different set of protocols for this situation. After this experience, make sure you know your protocols in-depth as it pertains to DNR circumstances. All in all you didn't adversely effect the situation, sounds like everyone got caught off guard. No worries, it happens to everyone. B)


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## usalsfyre (Apr 26, 2011)

medicstudent101 said:


> If you felt uncomfortable with the situation or wasn't a 100% sure about your protocols, there's NOTHING wrong with requesting ALS.


Other than tying up a finite resource for a call where there was no indication for it, and generating a needless bill?



medicstudent101 said:


> each state, and county for that matter, has a different set of protocols for this situation. After this experience, make sure you know your protocols in-depth as it pertains to DNR circumstances. All in all you didn't adversely effect the situation, sounds like everyone got caught off guard. No worries, it happens to everyone. B)


Agreed, if your regularly transporting hospice patients you should know the policies surrounding DNRs inside out.


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## Veneficus (Apr 26, 2011)

LucidResq said:


> That's what I'm wondering too. I've heard in some circumstances the legal thing to do would be to actually stop the rig and wait for the coroner. I'm not sure if that's true or not.



I think rather than call the coroner it might be more expediant to call medical control and ask if they would declare death if they are legally permitted to do so remotely with the testimony of a recognized observer.

Where I am from getting a coroner or representative could take hours possibly up to a day. That is a long time to wait.


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## Sasha (Apr 26, 2011)

Veneficus said:


> I think rather than call the coroner it might be more expediant to call medical control and ask if they would declare death if they are legally permitted to do so remotely with the testimony of a recognized observer.
> 
> Where I am from getting a coroner or representative could take hours possibly up to a day. That is a long time to wait.



I've been reading too much zombie fiction to sit with a dead guy more than a few minutes.


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## medicstudent101 (Apr 26, 2011)

Sasha said:


> I've been reading too much zombie fiction to sit with a dead guy more than a few minutes.



I second that.


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