83 y/o N/V + Fever

[VFlutter]

my experience is mottling is up to several hours, but not days.
That is just personal experience, not by the book.

Ever see an acute arterial occlusion? Mottling can happen in minutes.

What does a DNR have to do with treatment of this patient in her current state?

I am a huge advocate for non-aggressive treatment and palliative care however with most DNR patients the expectation is that they receiving aggressive standard care up until the point of cardiac arrest. Unless the patient is hospice.

Personally, I do not think the paramedic should be making calls to contact the family about treatment decisions. That is the MDs responsibility and they are the ones who can legally take verbal consent to stop treatment.

 

[triemal04]

First I am going to talk to family if they are there or reachable by phone and ask what their plans for treatment are or try and get a general feeling of how much they want done.

2. O2 up to a non rebreather, not putting this patient on Cpap unless the family is specifically requesting that "Everything" be done.
3. Iv and a bag of fluids.


Nothing else, certainly no medications. Average of a 25 minute ride to the hospital and the ER physician can talk to the family and see if they want antibiotics or anything or just a simple o2 mask and some morphine.

This patient is sick, based on presentation very very few of the people with those vitals survive long, especially if there is an extensive medical history (which I would suspect). Hopefully the family is at peace, time to let the body do what it is supposed to do.

This.

Before any type of care is rendered it needs to be determined how much care this patient actually wants. Make no mistake, that is entirely part of the job of a paramedic, and must be done first.

Pt in a DNR

Tell me more about the patient's DNR. Does it specify any other care beyond "no CPR?" Since he has a DNR, what did his advance directives, if any, say.

pt baseline gcs 9, non verbal

This sounds like someone who is very likely to have a power of attorney. What did they say when you contacted them?

I'm sure the OP did all this, but it remains that this needs to be done in this situation.

I am a huge advocate for non-aggressive treatment and palliative care however with most DNR patients the expectation is that they receiving aggressive standard care up until the point of cardiac arrest. Unless the patient is hospice.

Personally, I do not think the paramedic should be making calls to contact the family about treatment decisions. That is the MDs responsibility and they are the ones who can legally take verbal consent to stop treatment.

Actually, many states have various levels of care that go with a DNR; they DO NOT always recieve aggressive care until their heart stops, nor is that always in their best interest.

Contacting a patient's POA (if there is one) is absolutely something that every paramedic should be doing, and should be comfortable in doing.

 

[teedubbyaw]

This.

Before any type of care is rendered it needs to be determined how much care this patient actually wants. Make no mistake, that is entirely part of the job of a paramedic, and must be done first.

Tell me more about the patient's DNR. Does it specify any other care beyond "no CPR?" Since he has a DNR, what did his advance directives, if any, say.

This sounds like someone who is very likely to have a power of attorney. What did they say when you contacted them?

I'm sure the OP did all this, but it remains that this needs to be done in this situation.

Actually, many states have various levels of care that go with a DNR; they DO NOT always recieve aggressive care until their heart stops, nor is that always in their best interest.

Contacting a patient's POA (if there is one) is absolutely something that every paramedic should be doing, and should be comfortable in doing.

This patient has a treatable illness. She is unlikely to code en route. Treat and go. No reason to try and play phone tag with family and scare them.

 

[Carlos Danger]

This patient has a treatable illness. She is unlikely to code en route. Treat and go. No reason to try and play phone tag with family and scare them.

Yeah, this is how I see it as well.

The nursing home staff should be able to give basic info, i.e., supply you with a DNR or other advance directive as part of the transfer paperwork.

Beyond looking through the paperwork quickly and asking the referring "does this patient have an advance directive?", I wouldn't waste time "investigating". This is a sick patient who needs to be managed and transported. Normally the nursing home would already have called the family and let them know what is going on, long before transport arrives.

Unless told otherwise, I think it is always safe to assume that normal care is the expectation.

 

[NomadicMedic]

This is why a specific MOLST/POLST form needs to become a standard document in patients with advanced directives in place. Playing the guessing game with nursing home staff and family is certainly not in the patient's best interest. However, neither is starting treatments that may be discontinued on arrival at the ED. A clearly defined "menu" of patient approved treatments and interventions should be included in the packet of every long term care patient.

 

[mycrofft]

Stray shots:

1. Remember the elderly (especially the very elderly…say, a couple years past me) don't always exhibit a fever as promptly as youngsters do.

2. Not uncommon for elderly septic, especially pneumonia, to have disturbances of mentation, delirium, and lapsing in/out of consciousness.

3. We have a new paradigm. Just as "all bleeding stops eventually", then "In a DNR case, all arrythmias end eventually".

4. Nausea and vomiting….electrolytes? Exhaustion?(Says N/V on the thread title but not referred to in the thread's body by the OP).

 

[Handsome Robb]

FWIW I make contact with POAs on a daily basis at work.

Even in a time critical situation there's time to at least make an attempt to get a hold of them on the phone. Doesn't take that much time to have staff find the number for you and then to dial it and leave a message if no answer.

 

[Clipper1]

First I am going to talk to family if they are there or reachable by phone and ask what their plans for treatment are or try and get a general feeling of how much they want done.

2. O2 up to a non rebreather, not putting this patient on Cpap unless the family is specifically requesting that "Everything" be done.
3. Iv and a bag of fluids.


Nothing else, certainly no medications. Average of a 25 minute ride to the hospital and the ER physician can talk to the family and see if they want antibiotics or anything or just a simple o2 mask and some morphine.

This patient is sick, based on presentation very very few of the people with those vitals survive long, especially if there is an extensive medical history (which I would suspect). Hopefully the family is at peace, time to let the body do what it is supposed to do.

You have just confirmed why patients, families, DPOAs and physicians are reluctant to sign off on DNRs. They fear the DNR will be interpreted as Do Not Treat and the patient will suffer needlessly.

You have no definitive diagnostic data to base your decision. You are also asking the family or DPOA to call it quits for something which could easily be treated and the patient returned to baseline within 24 hours. This is not a "general feeling" but a decision which could end this person's life early for a treatable cause. You are also making the family make a decision for not doing medical treatment which they probably have never heard of like CPAP. They are not physicians and do not know if antibiotics and fluids would help especially if there is no lab work or other diagnostics to back up this decision. This is not an informed decision and the patient's heart has not stopped. With your phone call you are probably directing them to make decisions based solely on your own personal feelings and not the appropriate medical information. You may have hated all of those nursing home calls and now is your opportunity for a little "mercy" life ending or whatever you might prefer to call it. You need to defer to a physician and treat the patient appropriately along with not wasting time.

I am also going to suggest you take a geriatric medical emergencies class to learn more about how the most common illnesses can present poorly in the elderly but also can be easily treat.

 

[teedubbyaw]

Well said. Editing this post so I don't get an infraction for saying what should be said about a questionable person.

 

[VFlutter]

FWIW I make contact with POAs on a daily basis at work.

Even in a time critical situation there's time to at least make an attempt to get a hold of them on the phone. Doesn't take that much time to have staff find the number for you and then to dial it and leave a message if no answer.

Do you feel like you have the medical knowledge and experience to confidently tell a patient'a family that medical treatment is futile? Do you think that you have the adequate information in the field to make that call? Do you have a solid understand of what happens to these patients after the ED? This is not an attack but rather a legitimate question.

I am all for calling and clarifying wishes but if you are pushing them towards a certain treatment plan then you are in a grey area that I think is best left to the Physican. I am constantly amazed what 24-48hrs of IV fluids and antibiotics can do for some of these patients.

 

[teedubbyaw]

"Grandma is running a fever and has a rash. Would you like me to treat her?"

 

[Handsome Robb]

I don't think there's any question on if we treat this patient. The question is how aggressive are we?

Most SNF patients have an AD that defines what can and cannot be done during their care. If they don't call and ask. Be objective when you talk to family and be simple, they don't need a long complex explanation, "your father/mother has a high temperature and a low BP which indicates a severe infection that may have spread to their blood stream. Would you like us to use medicine to raise their blood pressure if we need to? Would you like us to place a breathing tube if needed? Would you like the patient transported to the hospital, if so, would you like them to give the patient antibiotics?"

It's that simple.

I agree that many disease processes affect the elderly much more than younger patients however I think we can all agree that this patient is well down the SIRS/Sepsis pathway, if be willing to go as far as saying they're entering into decompensated phases of septic shock. The morbidity and mortality for elderly is poor then add severe co-morbidities and it gets even worse. Sure it could be something simple and that needs I be considered but when you hear hoofbeats think horses not zebras.

 

[Clipper1]

It's that simple.

I agree that many disease processes affect the elderly much more than younger patients however I think we can all agree that this patient is well down the SIRS/Sepsis pathway, if be willing to go as far as saying they're entering into decompensated phases of septic shock. The morbidity and mortality for elderly is poor then add severe co-morbidities and it gets even worse. Sure it could be something simple and that needs I be considered but when you hear hoofbeats think horses not zebras.

That simple?

The SIRS/Sepsis pathway is for "survival" and decreasing morbidity. It is not intended to be used to tell the family to make a final decision. But, you are also making "assumptions". The lactate may not be at a notable level yet. The electrolytes and fluid status could be the primary.

If you have recognized all of this why are you not doing so form of treatment rather than just trying to coax the family into making a decision which then can justify you not doing anything and an easy transport.

The zebras and horses comment is also very unfounded since medicine does not always fit nicely into the rather limited Paramedic text.

 

[Tigger]

That simple?

The SIRS/Sepsis pathway is for "survival" and decreasing morbidity. It is not intended to be used to tell the family to make a final decision. But, you are also making "assumptions". The lactate may not be at a notable level yet. The electrolytes and fluid status could be the primary.

If you have recognized all of this why are you not doing so form of treatment rather than just trying to coax the family into making a decision which then can justify you not doing anything and an easy transport.

The zebras and horses comment is also very unfounded since medicine does not always fit nicely into the rather limited Paramedic text.

I think asking the family if they want invasive treatments performed on their loved ones is a legitimate question. I would much rather ask the family ahead of time "if their illness progresses to the x point they may require y intervention. Are you ok with this?"

This is not a justification for doing nothing. Far from it. This is trying to act in the patients best wishes.

Talk about assumptions.

 

[Clipper1]

I think asking the family if they want invasive treatments performed on their loved ones is a legitimate question. I would much rather ask the family ahead of time "if their illness progresses to the x point they may require y intervention. Are you ok with this?"

This is not a justification for doing nothing. Far from it. This is trying to act in the patients best wishes.

Talk about assumptions.

The DNR means somebody has spoken with the patient/family/DPOA but the family should also have some assurance they made the correct decision and that Paramedics will not provide treatment based on just a few vital signs still showing signs of life and no other diagnostics. It is also not in the patient's best interest to withhold treatment for something which could be treatable. Allowing someone to decline for something which is treatable is negligent regardless of the DNR. Calling a family member to condone this when you really have very little data should not allow you to have a get out of jail free card for what is mostly based on your personal beliefs and not medical diagnostics. You can not call yourself a patient advocate unless you have more to go on. In this scenario, you do not nor do you in most situations you encounter in prehospital. You are assuming when you make this life ending diagnosis.

 

[teedubbyaw]

Allowing someone to decline for something which is treatable is negligent regardless of the DNR.

I think this is the main point being conveyed. It seems some of you are looking at it as a whole, and not this particular patient.

I think we can all agree that this patient is fairly stable. Let the hospital deal with the 'fine print.'

 

[Handsome Robb]

That simple?

The SIRS/Sepsis pathway is for "survival" and decreasing morbidity. It is not intended to be used to tell the family to make a final decision. But, you are also making "assumptions". The lactate may not be at a notable level yet. The electrolytes and fluid status could be the primary.

If you have recognized all of this why are you not doing so form of treatment rather than just trying to coax the family into making a decision which then can justify you not doing anything and an easy transport.

The zebras and horses comment is also very unfounded since medicine does not always fit nicely into the rather limited Paramedic text.

Did I ever say that I coax families into anything? I take offense to that comment because I am far from lazy. The patient has a right to decisions about their care and if they're unable to make them and have appointed a POA that person has a right to make those decisions for them.

I didn't say anything about telling the family about the SIRS/Sepsis pathway. I said "your mother father has xx vitals that indicate a severe infection that may have spread to their bloodstream." How is that coaxing them into anything? I asked direct questions about specific treatments. If they answer with "do what you think is necessary" or another similar blanket statement I'll absolutely treat that patient to the standard of care without violating the DNR order or AD.

I can very easily make a phone call while the FD and my partner work on getting a line and fluids going and get them moved over and packaged for transport.

Fine it's a cliche comment. But are you going to look for the most complex diagnosis possible or are you going to look at the objective assessment in front of you and form a working diagnosis with the tools that you have? What does it change if this person has an easily correctable infection or advanced SIRS change about your treatment of this patient in this scenario?

It doesn't matter what the situation is the POA should always be contacted if there's something going on with the patient they're in charge of making decisions for. Routine or emergent.

It's very obvious you assume that no paramedic can possibly converse with a family member/POA in an objective manner.

 

[Clipper1]

Did I ever say that I coax families into anything? I take offense to that comment because I am far from lazy. The patient has a right to decisions about their care and if they're unable to make them and have appointed a POA that person has a right to make those decisions for them.

I didn't say anything about telling the family about the SIRS/Sepsis pathway. I said "your mother father has xx vitals that indicate a severe infection that may have spread to their bloodstream." How is that coaxing them into anything? I asked direct questions about specific treatments. If they answer with "do what you think is necessary" or another similar blanket statement I'll absolutely treat that patient to the standard of care without violating the DNR order or AD.

I can very easily make a phone call while the FD and my partner work on getting a line and fluids going and get them moved over and packaged for transport.

Fine it's a cliche comment. But are you going to look for the most complex diagnosis possible or are you going to look at the objective assessment in front of you and form a working diagnosis with the tools that you have? What does it change if this person has an easily correctable infection or advanced SIRS change about your treatment of this patient in this scenario?

It doesn't matter what the situation is the POA should always be contacted if there's something going on with the patient they're in charge of making decisions for. Routine or emergent.It's very obvious you assume that no paramedic can possibly converse with a family member/POA in an objective manner.

The POA is always contacted by the sending facility and then again by the rec'g facility.

You are asking the POA to make a decision based solely on your assumptions and personal feelings without any data other than vitals to back it up and those vital signs could be from many other things.


A patient also has the right to be treated. They did not sign away their right to be treated by signing a DNR. After reading this discussion, people probably should be afraid to sign a DNR. Patients have the right to not suffer needlessly and they have the right adequate medical treatment by the appropriate providers.

You do not violate a DNR by treating a patient who still has a heartbeat. DNR does not mean DO NOT TREAT.

 

[Wheel]

The POA is always contacted by the sending facility and then again by the rec'g facility.

You are asking the POA to make a decision based solely on your assumptions and personal feelings without any data other than vitals to back it up and those vital signs could be from many other things.


A patient also has the right to be treated. They did not sign away their right to be treated by signing a DNR. After reading this discussion, people probably should be afraid to sign a DNR. Patients have the right to not suffer needlessly and they have the right adequate medical treatment by the appropriate providers.

You do not violate a DNR by treating a patient who still has a heartbeat. DNR does not mean DO NOT TREAT.

I don't think he ever said that a DNR means do not treat. He said he'd contact a POA for a pt who can't speak for themselves regarding their treatment, and that also has a DNR.

 

[rhan101277]

The patient had a DNR on the physician orders paperwork. Not a normal kind of DNR w/ two physician signatures where it shows what they would or would not like done. Families need to be made aware and nursing home staff aware that these exist/