First patient death

[DragonClaw]

First call of the day.

97 YOF, recent STEMI. Taking her home on hospice with DNR. We make scene and my partner is primary. He gets a small report, not much to say on it.

We don't allow riders unless they are or accompanying a minor.

Right before departure the family is having second thoughts on it. We check with sup, they'll allow a rider in this case. The dr made sure to let the family know that she could go any second. That she might not make it home. They want to try and bring her home though.

They decide to transport her. It's only a 10 minute transport. Son comes with.

We barely make it out of the parking lot and my partner can't find a pulse and she's not breathing. Per sup, continue to destination. We cannot pronounce and she's been discharged already.

The hospice sent equipment for her, oxygen and comfort measures but the hospice nurse wasn't there yet. They're not sure if they can pronounce or not. Sup kicks around the idea of sending JP or ME but we hold off until the nurse gets there. Like 30 minutes after our arrival.

The son completely understood that she could have died in transport and then did. The woman at the house (unsure of the relationship) was upset. I know no amount of dr talk can prepare you for the moment it happens and it's a lot of pressure and stress but she kept changing her mind

We were waiting on the nurse to see if she would call it. We called their company and asked what their protocols were to try and save some time. Their clinical coordinator didn't know and she says to wait for the nurse to get there.

The female present was upset the nurse wasn't there and ready. She was upset the hospital apparently urged the discharge. She was happy the pt was home. She wanted the pt's body to go to the morgue/funeral home immediately. So I'm not really sure what she wanted.

The nurse arrived and confirmed she could call it. So we moved her body inside and the nurse signed the report and called the funeral home to come get the body

We went out to the truck and a different lady who was part of the family came out to thank us for bringing her home so they could say goodbye. Then we left.

Part of me is kinda .... I wish I could have done something. I originally felt like we failed. That we didn't get her home alive, but then I got to thinking. Everyone knew the moment was near and that it could very well happen in the ambulance. We got to our destination safely and by the book. There's nothing more I could have done.

But the mere fact I can't do anything more seems... I dunno. Just kind of memento mori.

And I guess that's it. The human condition is terminal and she was surrounded by loved ones, her son was there when she died.

But I just wish I could have done more.

Maybe that sounds like I have a God complex. Maybe I do have one.

I dunno.

It was just pretty cut and dry. She's dead and didn't make it home alive.

Thoughts?

Edit: The not allowing riders is due to the Rona.

 

[DesertMedic66]

The point of DNRs is to allow the patient to die hopefully peacefully in an environment they are comfortable with. What we can do for these patients is to make them comfortable, show respect to them, and try to make their wishes happen.

You were a part of that goal. Yes, the patient didn’t make it home but you were still attempting to complete that goal. You will not be able to save all of your patients and in some cases the better option is to let them go.

It is a shame that in your system you guys are not able to pronounce patients.

 

[DragonClaw]

The point of DNRs is to allow the patient to die hopefully peacefully in an environment they are comfortable with. What we can do for these patients is to make them comfortable, show respect to them, and try to make their wishes happen.

You were a part of that goal. Yes, the patient didn’t make it home but you were still attempting to complete that goal. You will not be able to save all of your patients and in some cases the better option is to let them go.

It is a shame that in your system you guys are not able to pronounce patients.

I never really thought I could "save" her. She was old and frail and... old. She was unresponsive the whole time and looked like death. Her HR was in the 30s as we left, she was barely breathing.

I don't want to sound I told you so. But I honestly didn't think she was going to make it and I'm glad she had a DNR.

But even with that being said I wished I could have saved (help her live a longer healthy happy life) her or done something?

I have no idea if what I'm saying makes sense.

 

[silver]

I never really thought I could "save" her. She was old and frail and... old. She was unresponsive the whole time and looked like death. Her HR was in the 30s as we left, she was barely breathing.

I don't want to sound I told you so. But I honestly didn't think she was going to make it and I'm glad she had a DNR.

But even with that being said I wished I could have saved (help her live a longer healthy happy life) her or done something?

I have no idea if what I'm saying makes sense.

You mentioned that you were bringing her home on hospice? Hospice is end of life care with a focus on the comfort and dignity of the patient while also providing the psychological and spiritual support to family/care takers. You provided the utmost care to this patient at the end of her life by having her be comfortable and also provided the family with ease by bringing her home to die.

 

[Martyn]

Sounds like you did OK. I have been through this several times, once, after a 60 mile trip to a hospice the patient expired as we put her into the bed at the hospice. Nothing can prepare you for the first time it happens. Take solace in the fact she was with loved ones and that she went peacefully. The only thing you can do in this situation is be professional...you have a job to do. I tend to transfer my care from the deceased to caring for the relatives and friends once they have passed.

I would also like to add it is good to talk about your feelings after an event like this.

 

[Billyd]

You did everything you needed to do correctly and compassionately and that is why the family member thanked you at the end. We had a similar case last week but no death.
Arrived to hospital, 79yo male with multiple myeloma. Get report from nurse who said he was brought in due to being weak, got multiple blood transfusions throughout the course of his stay (5-7 days) and is being discharged home for hospice. Made pt contact and the guy was awesome. Talkative, practically buckled himself in lol and even had his wife bring the nurse the remaining N95 masks from his house as a donation.
We started talking in the back of the rig and he pretty much said that he is tired of the treatments as it is affecting his quality of life (vomiting, dizziness, weakness) and he decided he wants to go home and die even though his children want him to keep fighting. Told me he had less than a week to live.
Almost lost it when we were wheeling him into the house and all of his family was there. They were excited to see him as they were no visitors allowed in the hospital due to Coronavirus but some of them were starting to cry, because they knew he made his decision.
I got in this industry because I love helping and interacting with people. It sucks sometimes when you know the outcome isn't going to be good no matter what you did or could have done. I just wish my father, who passed away suddenly in a ****ty hospital a year ago, had the chance to go peacefully in his own house.

 

[Akulahawk]

I have said this often, and those that know me can attest: "The patient isn't my only patient. The family is as much the patient as the patient is." Once you understand this, taking care of the dying is the same as taking care of the living, just with a different focus. This is something I have said and done some 20 years now. If you have a patient that is DNR and is actively dying, your focus is literally on comfort care of the patient and their family. It matters not whether you're in-hospital or transporting home. It's the same. If your patient codes and eventually is determined/pronounced deceased, again, it's the same.

It sounds like you have done what you should. Make peace with Death for Death will be not be an unknown, and sometimes frequent, visitor.

 

[DragonClaw]

Thank you for your kind words and advice y'all .

I guess I'm just kinda bummed I couldn't give the family just a little more time so everyone could say goodbye while she was alive.

But they said she had an awesome last 2 weeks. He BP and everything was stellar. She was walkie talkie. Then a few days ago she just didn't feel good then STEMI that rapidly progressed to where we are now.

Part of me also wanted to do CPR though. Not because "Oh I'm sure we could have "saved" her" or anything. Just when your partner announces the apnea and pulselessness you just want to CPR? I dunno. Maybe I'm just being weird but you get it hammered into you check for breathing and pulse and OKAY CPR GOOOOOOOOO.

But there's no way I'd violate a DNR and obviously that would have only made everything worse. It just feels kinda conflicting and that while I did everything I could I just wanted to do more. For her, for the family.

 

[ffemt8978]

Careful making absolute statements about doing or not doing something. This field has a way of making you eat those words eventually.

 

[DragonClaw]

Careful making absolute statements about doing or not doing something. This field has a way of making you eat those words eventually.

But... isn't a DNR absolute?

Will momentarily contradict myself obviously. But unless the family recinded it, I have no legal reason to start CPR. Ethically is a tougher thing to divide up.

 

[Peak]

If her placement on hospice is like most then there is a good chance that the family waffled for several days before agreeing to hospice in the literal last minutes.

You didn’t delay her disposition so you shouldn’t feel guilt for that part. A sick old lady with a heart rate of 30, agonal respirations, and altered mental status from inadequate perfusion is actively dying and you can’t change that.

You do the best to support the family. Death is part of the circle of life, 97 is a long life.

 

[Peak]

But... isn't a DNR absolute?

Will momentarily contradict myself obviously. But unless the family recinded it, I have no legal reason to start CPR. Ethically is a tougher thing to divide up.

There is a lot that goes into advanced directives and varies based on state laws. There are situations in which DNRs become invalid, and families don’t necessarily have a right to rescind a DNR at the last minute. Also if the patient presents an acutely irreversible fatal pathology then we are not necessarily obligated to perform resuscitation (in a blindingly obvious example patient found pulse less with fixed lividity, or a patient with known end stage heart disease who is not a candidate for intervention and has an EF or less than 5%).

 

[DragonClaw]

If her placement on hospice is like most then there is a good chance that the family waffled for several days before agreeing to hospice in the literal last minutes.

You didn’t delay her disposition so you shouldn’t feel guilt for that part. A sick old lady with a heart rate of 30, agonal respirations, and altered mental status from inadequate perfusion is actively dying and you can’t change that.

You do the best to support the family. Death is part of the circle of life, 97 is a long life.

Yeah. All our calls were hospice pts. Most with DNR. Our last call was a 21YOF on hospice for brain cancer that metastasized. But they rolled the call to another unit due to pickup time and our EOS.

I know her time was near and she'd had a good full life. That part was nice. She had her family there for her and that was that.

I started down the trail of "If we'd gotten dispatched earlier. If we'd made scene sooner. Etc"

But honestly, that's all/mostly out of my hands. If we'd been stuck in traffic for a few minutes she'd died in the hospital.

My partner told me before we made pt contact to drive a little faster, but not crazily so. Just be real direct on the driving. But judging that like 2 minutes after loading her up any dr would have called it, there's no amount of driving skill in the world that could have done it.

I'll be okay I just keep wishing there was something more I could have done. But there's not. I did everything right and safely and timely. It is what it is.

 

[VentMonkey]

97 is a long life.

This. Once you’re able to transition into a
faster paced system, i.e., 911-system, you will see all walks of life cut short by death itself.

Sometimes directly, and horrifically in front of said loved ones (mom trying to separate her kids from fighting in the back while driving, who rolled, suffering the only mortal wounds in front of her kids old enough to know what just happened still gives me chills...)

I also agree with the post that said it’s not unhealthy to discuss these things in spite of dated dogmas.

Also, the “Reaper Racer” types will never win their made up quest for heroics. Death will inevitably beat them when it sure enough sees fit.

 

[DragonClaw]

This. Once you’re able to transition into a
faster paced system, i.e., 911-system, you will see all walks of life cut short by death itself.

Sometimes directly, and horrifically in front of said loved ones (mom trying to separate her kids from fighting in the back while driving, who rolled, suffering the only mortal wounds in front of her kids old enough to know what just happened still gives me chills...)

I also agree with the post that said it’s not unhealthy to discuss these things in spite of dated dogmas.

Also, the “Reaper Racer” types will never win their made up quest for heroics. Death will inevitably beat them when it sure enough sees fit.

Yeah I know she had a decent death, if one may call it that. She was old it was her time. He son was with her and her family recieved her body.

Is it wrong to have wanted just a few more minutes?

What do you mean reaper race. Memento Mori afterall. Despite anyone's best efforts, when it's your time it's your time. Doesn't mean I am happy about it but death cares not for my feelings.

 

[E tank]

Not trying to be flippant, but if your partner insists on taking the pulse of a patient on her way to die at home, tell him to keep his mouth shut and just bring her home.

 

[ffemt8978]

But... isn't a DNR absolute?

Will momentarily contradict myself obviously. But unless the family recinded it, I have no legal reason to start CPR. Ethically is a tougher thing to divide up.

As @Peak pointed out, a DNR is not absolute. As an anecdote, when working at a private EMS company I had a transport of a hospice patient with valid DNR orders and Advanced Directive. The transport was taking the patient home across state lines so they could spend their remaining time with family. Patient tanked about 3 miles after we crossed state lines. Called into receiving facility to let them know what was happening, and they diverted me to the nearest ER. Called the ER and gave them a full report, and was told to work the patient despite the DNR/Advanced Directive.

I'm not saying you did anything wrong. Matter of fact, it appears as if you handled the call well. I'm just cautioning against absolutes in this field. Only two things in this field are absolute. Death never loses and there will always be exceptions.

 

[Jim37F]

I remember years ago back in my very first EMT job, I had an almost identical call. Pick up patient from hospice who is actively CTD, and take them home to die there with family.

I don't remember all the details (this was like 7 years ago now), but I was also a green EMT, first job, only a few months after getting my cert, pretty much all my experience was Cedars to SNF discharges and non-Kaiser to Kaiser transfers. That was pretty much the first time I'd been sole attendandt on a legit sick person, one who was very definitively dying at that.

I can tell you I felt pretty much the exact same anxiety you're describing Dragon. Obviously, logically i knew, then as now, I wasn't going to start CPR, or call ALS (which would basically have meant calling 911 for Fire to show up), but still, sitting there with someone on the edge, who may go over during the transport had me racing in circles in my mind as well.

For me, my patient held on long enough to get home and allow us to finish the call.
I say the patient held on because there was nothing I could have done to change that, nothing you could have done for yours.

It sounds like you did as much as what very little we can do in these cases. Provide transport in accordance with their wishes and try to keep them as comfortable as possible.

I know its not a fun call, but you did as good as anyone else could have done, and now, hopefully your patient and their family can have peace.

 

[DragonClaw]

Not trying to be flippant, but if your partner insists on taking the pulse of a patient on her way to die at home, tell him to keep his mouth shut and just bring her home.

Um, why. ? Shouldn't we know if our patient is dead. Someone is going to notice she's not breathing.

 

[E tank]

Um, why. ? Shouldn't we know if our patient is dead. Someone is going to notice she's not breathing.

Maybe, maybe not. At the end of the day, the purpose of bringing this lady home was for the consolation of the family so that they could gather around her at the time (not minute) of her death. Not Monday morning quarterbacking here. When and where she died or even if she died had nothing to do with the call you were on. Neither was "calling it" or not...

Re-reading your post, it wasn't immediately clear to me that you brought the body into the house after she had died, that you had not waited for a hospice nurse to confirm the death before going in. Not the case from what I now read.