83 y/o N/V + Fever

[triemal04]

Many, Many, Many people? Maybe it is more prevalent in your area however I have never seen a single patient come in with a "Comfort Measures Only" DNR that was leading anything close to a "normal life". I have seen many people who have DNRs that come in who are quite independent and relatively healthy, but we are talking about two totally different things. I have also never discharged a patient home on comfort measures without some type of in-home care. Which I do on a weekly basis with many of our end stage patients.

You need to step outside your bubble for a bit and realise that there is more to medicine than your part, and things that you won't deal with.

I do not know many people who are living normal lives who choose to die from a UTI or would refuse treatment for an allergic reaction.

Which is the beauty of these things; patients may change their mind at anytime they choose. And when told that they have a relatively minor and easy to treatement problem, many do.

But obviously it seems that you know more than I do.

I see more patients in much more varied settings than you do. There are plenty of patients that I see that, because of their choices, will never be seen by anybody who works is a hospital. So yes, in this situation I DO know more than you.

Don't make this a **** measurin contest, ok.

 

[Clipper1]

Which is the beauty of these things; patients may change their mind at anytime they choose. And when told that they have a relatively minor and easy to treatement problem, many do..

But such as in the scenario here, the person might be unresponsive from a UTI which could be easily treated. This is not uncommon in the elderly. However, as suggested by some here, the Paramedic might call the family and call it quits. The patient may not have wanted to have their life terminated for a UTI and may have accepted treatment if responsive. Her heart had not stopped.

I see more patients in much more varied settings than you do. There are plenty of patients that I see that, because of their choices, will never be seen by anybody who works is a hospital. So yes, in this situation I DO know more than you.

Don't make this a **** measurin contest, ok.

You PICK UP patients in various settings but you don't always see what happens to them in the hospital. You also don't see the patients brought in by other ambulances or by families. How many patients are in the hospitals you deliver to on any given day? How many of those patients are yours? How many kids do you think are "comfort care" in your area that you know of? Can you describe the hospitals and Hospice Palliative care protocols in your area? What training do you have in Palliative care and Ethics? Have you ever been on an Ethics meeting to determine the end of life process and the palliative care for a patient? Have you actively participated in end of life by withdrawing life support? This does not mean stopping a code.

 

[Carlos Danger]

I don't mean to be rude, but you clearly do not understand why people call 911, who is calling, or what type of "comfort care" may be needed. Many people call because they aren't sure of what to do, are panicking, don't know what the actual patient wants, or because they are required to (for someone living in an assisted-living center for instance).

Huh? Chase said that if the patient didn't want to be treated, then EMS should never have been called.......he didn't say people NEVER call EMS for these things. Saying that something shouldn't happen is not the same thing as saying something doesn't happen. Is it?

Perhaps these are reasons why people DO call EMS, but are they reasons why they SHOULD call EMS? I don't think so. Chase was right. People shouldn't call EMS in these situations. Just because they sometimes panic and do so doesn't mean we should promote it.

Now if there is intractable pain or something that isn't being effectively managed, then that's different. But even then, the best course is probably to get new orders from whoever is writing them, if that is an option.

If you don't want your car towed to an auto mechanic, you don't call a tow truck. If you don't want to be treated at a hospital, you don't call EMS. Pretty simple.

This of course ignores the fact that "comfort care" is very much something that we can provide to many patients, and should when appropriate. Sometimes this very well may mean that the patient is taken to the hospital.

So what is this magical "comfort care" that you can provide, that the nursing home staff and palliative care team cannot?

Any patient that has been made "comfort care" is already being managed by a hospice or palliative care team. This patient in question was already in a nursing facility and already has orders and is already being managed by a physician. They should be able provide for his comfort needs.

Do you really think the patient would be more "comfortable" being stuffed into an ambulance and taken to the hospital where he'll lay in a noisy, brightly lit room for a day or so while the doctors figure out what to do with him and eventually just send him back to his nursing home, and then send his family a hefty bill for TWO ambulance transports and a work up at the hospital? That is pretty much exactly what would happen if you took a patient to the hospital who wants only comfort care.

 

[Clipper1]

Any patient that has been made "comfort care" is already being managed by a hospice or palliative care team. This patient in question was already in a nursing facility and already has orders and is already being managed by a physician. They should be able provide for his comfort needs.

That is not correct. Unfortunately comfort care does not automatically come with a hospice or palliative care team. Some hospitals don't have palliative care teams and it is the luck of the draw for the patient if they get a doctor who understands "comfort care". Different facilities have different protocols and levels of care they can provide. Nursing homes without a palliative care unit for exception to the state guidelines for the care provided are very, very limited for the medications they can provide. The same with sub-acutes with ventilator patients. SNFs are a little better. But then placement into a facility becomes a wallet or insurance biopsy which appears to be your concern also. Sometimes it is best to transport to a hospital when these patients' pain and comfort can no longer be managed in the nursing home. Other health care providers have to watch the suffering all shift while you are just there for 15 minutes to voice your "opinion".

Do you really think the patient would be more "comfortable" being stuffed into an ambulance and taken to the hospital where he'll lay in a noisy, brightly lit room for a day or so while the doctors figure out what to do with him and eventually just send him back to his nursing home, and then send his family a hefty bill for TWO ambulance transports and a work up at the hospital? That is pretty much exactly what would happen if you took a patient to the hospital who wants only comfort care.

Some hospitals now have hospice room set up for the comfort of the family and patient. These patients are suffering or at least give a strong appearance of suffering with a great deal of care required to alleviate it. Some also are difficult to place in any care facility due to the meds. Some are not a candidate for home since the family's training for all of the devices will take longer than death itself. Some families who opted to take the patient home thought they were doing the best thing but didn't realize all the adjustments which would be needed physically and emotionally in a household. You really should not hold it against the patient or the family for this.

And some call 911 when they feel helpless. It is difficult to watch a loved one die and not be able to control their discomfort. You can talk big but if your child or wife was crying out in pain and the meds available were not working would you really care what it costs to transport them back to the hospital to get the pain under control? Some also make assumptions that hospice and nursing homes are only for the very old who probably need to die but that is simply not true. Nor should you make assumptions that a facility can provide everything needed with just a doctor's order. Check your own state and see how many different levels of facilities there are and what can or can not be done in each. A Paramedic is also very limited and might only be able to do something for the short term but chances are the medications they carry are the same as the nursing home with the same limitations. This is why transport might be required rather than leaving a patient to suffer and not get the opportunity to be placed in a facility which can provide a higher level of comfort.

 

[Carlos Danger]

That is not correct. Unfortunately comfort care does not automatically come with a hospice or palliative care team. Some hospitals don't have palliative care teams and it is the luck of the draw for the patient if they get a doctor who understands "comfort care". Different facilities have different protocols and levels of care they can provide. Nursing homes without a palliative care unit for exception to the state guidelines for the care provided are very, very limited for the medications they can provide. The same with sub-acutes with ventilator patients. SNFs are a little better. But then placement into a facility becomes a wallet or insurance biopsy which appears to be your concern also. Sometimes it is best to transport to a hospital when these patients' pain and comfort can no longer be managed in the nursing home. Other health care providers have to watch the suffering all shift while you are just there for 15 minutes to voice your "opinion".

Some hospitals now have hospice room set up for the comfort of the family and patient. These patients are suffering or at least give a strong appearance of suffering with a great deal of care required to alleviate it. Some also are difficult to place in any care facility due to the meds. Some are not a candidate for home since the family's training for all of the devices will take longer than death itself. Some families who opted to take the patient home thought they were doing the best thing but didn't realize all the adjustments which would be needed physically and emotionally in a household. You really should not hold it against the patient or the family for this.

And some call 911 when they feel helpless. It is difficult to watch a loved one die and not be able to control their discomfort. You can talk big but if your child or wife was crying out in pain and the meds available were not working would you really care what it costs to transport them back to the hospital to get the pain under control? Some also make assumptions that hospice and nursing homes are only for the very old who probably need to die but that is simply not true. Nor should you make assumptions that a facility can provide everything needed with just a doctor's order. Check your own state and see how many different levels of facilities there are and what can or can not be done in each. A Paramedic is also very limited and might only be able to do something for the short term but chances are the medications they carry are the same as the nursing home with the same limitations. This is why transport might be required rather than leaving a patient to suffer and not get the opportunity to be placed in a facility which can provide a higher level of comfort.

All of which is why I qualified my statements by saying this:

Now if there is intractable pain or something that isn't being effectively managed, then that's different.

Obviously if the patient isn't getting the care they need, then they require transport to a different facility.

The overall point, however, was that if the dying person doesn't want hospital treatment, and the only reason EMS was called is because the family or staff of the dying patient "freaked out", then that is inappropriate. Understandable perhaps, but still inappropriate.

I love how you so frequently accuse others of "making assumptions", at the same time having speculated yourself that the person you are responding to has little or no experience with the topic being discussed.

 

[Clipper1]

The overall point, however, was that if the dying person doesn't want hospital treatment, and the only reason EMS was called is because the family or staff of the dying patient "freaked out", then that is inappropriate. Understandable perhaps, but still inappropriate.

Freaked out? What if it was your wife or child? What you might consider freaked out might just be concern or fatigue from watching a loved one die. You again are forming an opinion (and your personal opinion) from just a few minutes and not weeks or even a full shift of observing. The same goes for "staff freaking out". You are not there for 12 hours for several days. Many patients on comfort care can not carry on a normal conversation. Some patients are also "directed" as "what is best" by a family member or a doctor who just wants the patient out of the hospital and maybe even out of his care. Some of these patients are young women with breast cancer who wanted to continue the fight but were told by their insurance or doctor the next level would be too expensive. Since cost is one of your concerns you would probably understand it is best to just hope a patient dies before running up anymore cost. And then some patients are just dumps into a facility because of bed space and an easy way out of the cost thing. But, at some nursing homes there are actually patient advocates who fight to get a patient placed more appropriately and with a few calls to doctors and SWs or CMs, the patient is sent back to be placed more appropriately or put on hospice care inside the hospital.

Don't assume all family members or staff just freak out for no reason or that transport of comfort care patients to a facility which can actually provide a higher level of comfort as inappropriate. There is a lot you need to learn about the US health care system. There are resources on line which explains the level of care by facilities and hospice also has some great articles on how to use hospice and the limitations for use of hospice or just why some don't get the hospice care they need. You will then see why some of your comments are incorrect.

 

[Carlos Danger]

Freaked out? What if it was your wife or child? What you might consider freaked out might just be concern or fatigue from watching a loved one die. You again are forming an opinion (and your personal opinion) from just a few minutes and not weeks or even a full shift of observing. The same goes for "staff freaking out". You are not there for 12 hours for several days. Many patients on comfort care can not carry on a normal conversation. Some patients are also "directed" as "what is best" by a family member or a doctor who just wants the patient out of the hospital and maybe even out of his care. Some of these patients are young women with breast cancer who wanted to continue the fight but were told by their insurance or doctor the next level would be too expensive. Since cost is one of your concerns you would probably understand it is best to just hope a patient dies before running up anymore cost. And then some patients are just dumps into a facility because of bed space and an easy way out of the cost thing. But, at some nursing homes there are actually patient advocates who fight to get a patient placed more appropriately and with a few calls to doctors and SWs or CMs, the patient is sent back to be placed more appropriately or put on hospice care inside the hospital.

Don't assume all family members or staff just freak out for no reason or that transport of comfort care patients to a facility which can actually provide a higher level of comfort as inappropriate. There is a lot you need to learn about the US health care system. There are resources on line which explains the level of care by facilities and hospice also has some great articles on how to use hospice and the limitations for use of hospice or just why some don't get the hospice care they need. You will then see why some of your comments are incorrect.

Ahhh, OK.......

 

[triemal04]

Stop treating patients that DON'T want to be treated....there are way more of them out there than you would think...

Then they should have never called EMS.

If you don't want your car towed to an auto mechanic, you don't call a tow truck. If you don't want to be treated at a hospital, you don't call EMS. Pretty simple.

Many people call because they aren't sure of what to do, are panicking, don't know what the actual patient wants, or because they are required to (for someone living in an assisted-living center for instance). While the actual patient may not want care, (or even need care in some cases) the simple fact that 911 was called does not in any way, shape, or form mean that they have consented to treatement. Rialagh is very right; we need to stop treating people who don't want treatement.

I'm not going to repeat myself to much. We often get called to see people that do not WANT, or NEED our help. The simple fact that 911 was called or that we show up does not change this.

So what is this magical "comfort care" that you can provide, that the nursing home staff and palliative care team cannot?

Generally it's pain management. If the patient is in pain due to their chronic condition or a NEW problem that is presenting itself, we can, and should treat that as appropriate. It does not matter if the patient is in a nursing home; many, including skilled nursing homes, do not have the capabilities or drive to provide pain management beyond the patient's already prescribed regime. Hospice is different, but it still requires the hospice nurse to BE THERE, and potentially to have to stop at a pharmacy to get the needed medications. We very well may be the more appropriate initial response.

Any patient that has been made "comfort care" is already being managed by a hospice or palliative care team. This patient in question was already in a nursing facility and already has orders and is already being managed by a physician. They should be able provide for his comfort needs.

I'm sorry, but you people are living in a fantasy land. For many, many parts of the country a DNR with built in advance directives (POLST is one common name for it) is quite common, and getting even more common as time goes on. A "DNR with comfort measures" IS NOT something that only is given to people who are very near death as you and chase seem to believe. It IS NOT only given to patient's who are under hospice care or live in a skilled nursing facility; many people have it that lead very normal and healthy lives because...they are quite healthy.

If this trend towards making a determination about what type of invasive and longterm care is wanted before it is actually needed continues, you all need to wrap your heads around the fact that there are people who will want to die naturally and peacefully whenever it may happen, and they will make this determination before they ever become ill.

 

[Carlos Danger]

A "DNR with comfort measures" IS NOT something that only is given to people who are very near death as you and chase seem to believe. It IS NOT only given to patient's who are under hospice care or live in a skilled nursing facility; many people have it that lead very normal and healthy lives because...they are quite healthy.

If this trend towards making a determination about what type of invasive and longterm care is wanted before it is actually needed continues, you all need to wrap your heads around the fact that there are people who will want to die naturally and peacefully whenever it may happen, and they will make this determination before they ever become ill.

I completely understand that, in fact that is my WHOLE POINT, and I'm pretty sure at least part of what Chase was getting at, too.

Not sure exactly what your experience is or where the disconnect is here, except that you and Clipper seem to be looking so hard for opportunities to point out that others "need to learn about the healthcare system" and "need to wrap your heads around things", that you think you see them when they aren't there.

 

[triemal04]

I completely understand that, in fact that is my WHOLE POINT, and I'm pretty sure at least part of what Chases was getting at, too.

Not sure where the disconnect is here, except that you and Clipper seem to be looking so hard for opportunities to point out that others "need to learn about the healthcare system", that you think you see them when they aren't there.

No, I highly doubt that was the point of what he was getting at. And if that is your point, your comments make that exceeding hard to see.

If the patient and/or patient's family truly does not want treatment as in "Comfort Measures Only" then they should not be calling EMS and certainly not be transporting to the hospital. Most of these type of patients have home health and hospice care.

I have never seen a single patient come in with a "Comfort Measures Only" DNR that was leading anything close to a "normal life"..

Any patient that has been made "comfort care" is already being managed by a hospice or palliative care team.

You don't get it both ways.

Both of you are wrong. It's as simple as that. Learn from it, and move on.

 

[Carlos Danger]

Both ways?

I stated that when an individual has decided they'd rather die at home than be taken to a hospital, then their caretakers should respect that and not call EMS when their condition worsens.

That is essentially the same thing YOU wrote, AFTER telling Chase that he was wrong for saying it.

So one of us is trying to have it both ways, but it isn't me.

 

[triemal04]

Once again. This:

Any patient that has been made "comfort care" is already being managed by a hospice or palliative care team.

is completely, and utterly, WRONG.

Both of you have said essentially the same thing, and ARE WRONG. A "DNR with comfort measures only" is not something that is only given to people on hospice, and who are managed by in-home healthcare. In many parts of the country it is a very common thing, and many of the people who hold one live independantly with no need of hospice, or any type of home care.

Do you understand that, or not?

edit: It is very common to see patient's who, due to a sudden, potentially life ending event, are no longer capable of explaining what they want, and do not have a group of medical providers who deal daily with them present because they never had need for such. At that point, their POLST is very important, and people in EMS may be the first people (aside from the patient's primary care physician) to see it. You both seem to think that only people who were already ill or otherwise close to dying will have one; that is not true. Normal people often have a DNR/POLST/whatever in place. EMS needs to be aware of that, and understand that they will need to follow it, even if up until that moment the patient had been quite healthy.

 

[Carlos Danger]

Both of you have said essentially the same thing, and ARE WRONG. A "DNR with comfort measures only" is not something that is only given to people on hospice, and who are managed by in-home healthcare. In many parts of the country it is a very common thing, and many of the people who hold one live independantly with no need of hospice, or any type of home care.

Do you understand that, or not?

I never said or even implied that everyone with a DNR is in hospice or receiving home healthcare. You completely fabricated that. The term "DNR", doesn't even appear in any of my posts, so I don't know where you even got that from.

It sounds like you have some terms confused. "Comfort care" is a totally different thing from a DNR. A DNR is an advanced directive that comes from the patient. "Comfort care" is a management strategy for nursing staff and caregivers that generally requires a physician's order. Usually these patients have palliative care consulted and are referred to hospice where they are managed at home or in a facility. Specific circumstances vary, of course, as does terminology.

The bottom line is that any patient has the right to do whatever they want. Stay home, go to the hospital, enter hospice, don't enter hospice, whatever. My point was that a patient at the end of their life shouldn't be stuffed into an ambulance and taken to the hospital just because their condition worsens, when they've made it clear that they'd rather stay home. That is all.

I don't understand why you think people who'd rather stay home should be forced to go to the hospital. You should perhaps spend some time reading about advanced directive and the concept of self-determination.

 

[triemal04]

I never said or even implied that everyone with a DNR is in hospice or receiving home healthcare. You completely fabricated that. The term "DNR", doesn't even appear in any of my posts, so I don't know where you even got that from.
Perhaps because everything said has been about a "DNR with comfort measures only" or "comfort measures DNR."

It sounds like you have some terms confused. "Comfort care" is a totally different thing from a DNR. A DNR is an advanced directive that comes from the patient. "Comfort care" is a management strategy for nursing staff and caregivers that generally requires a physician's order. Usually these patients have palliative care consulted and are referred to hospice where they are managed at home or in a facility. Specific circumstances vary, of course, as does terminology.
It sounds like you are confused about what much of the country is doing in regards to standardized DNR and advance directive forms. You should probably rectify that, and make sure that your state doesn't have one.

The bottom line is that any patient has the right to do whatever they want. Stay home, go to the hospital, enter hospice, don't enter hospice, whatever. My point was that a patient at the end of their life shouldn't be stuffed into an ambulance and taken to the hospital just because their condition worsens, when they've made it clear that they'd rather stay home. That is all.
I agree completely. Your comments don't bear that out though.

I don't understand why you think people who'd rather stay home should be forced to go to the hospital. You should perhaps spend some time reading about advanced directive and the concept of self-determination.
I don't think that at all, and have never said anything to that effect. Please, by all means point out one instance. I have said and implied that EMS treatement may be needed, and potentially transport might even be needed IF the patien'ts needs can't be met in their current situation.

If you don't want your car towed to an auto mechanic, you don't call a tow truck. If you don't want to be treated at a hospital, you don't call EMS. Pretty simple.

I would very much like to hear your explanation for saying this. As I said twice, 911 may be called in error for many reasons, and the simple fact that 911 was called does not mean that the actual patient needs, or wants our help. Here you would seem to be saying the opposite.

Explain yourself.

 

[VFlutter]

Both of you are wrong. It's as simple as that. Learn from it, and move on.

That is a bold statement to make. Let's agree to disagree. I will respond further when I get off work.

Ironically, I just got done making a patient comfort measures only. If they do leave the hospital the expectation is that they will not return.

 

[Clipper1]

I would very much like to hear your explanation for saying this. As I said twice, 911 may be called in error for many reasons, and the simple fact that 911 was called does not mean that the actual patient needs, or wants our help. Here you would seem to be saying the opposite.

Explain yourself.


It sounds like you have some terms confused. "Comfort care" is a totally different thing from a DNR. A DNR is an advanced directive that comes from the patient. "Comfort care" is a management strategy for nursing staff and caregivers that generally requires a physician's order. Usually these patients have palliative care consulted and are referred to hospice where they are managed at home or in a facility. Specific circumstances vary, of course, as does terminology.

It sounds like you are confused about what much of the country is doing in regards to standardized DNR and advance directive forms. You should probably rectify that, and make sure that your state doesn't have one.

Comfort Care, Advanced Directives, DNR and DNI are all very different terms with very different treatment plans.


Comfort Care is defined in EVERY state (all 50) in the United States because of CMS and reimbursement. This includes Washington as well as Oregon, California, Montana etc. This does not mean every facility is equal unless they have some level of providing hospice services if the patient meets the qualifications. The qualifications are determined by a physician and maybe the Ethics committee by the legal guidelines of that state. CMS is involved because of reimbursement and acceptance into a facility or service. It is not up to the Paramedic to decide a patient should be a DNR or in Comfort Care and make this so by just calling the family.

 

[Clipper1]

Both ways?

I stated that when an individual has decided they'd rather die at home than be taken to a hospital, then their caretakers should respect that and not call EMS when their condition worsens.

That is essentially the same thing YOU wrote, AFTER telling Chase that he was wrong for saying it.

So one of us is trying to have it both ways, but it isn't me.

Chase and I also agreed about reasons for a patient who is in comfort care to be brought to the hospital. Example: If their PICC or indwelling port (special "IVs") is not functioning, they will not be able to receive the comfort meds. For this EMS should transport. I guess the family could try to get a patient this brittle into their POV. Dying in comfort is the objective here.

Until you have actually worked with these patients for longer than the few minutes you spend on scene, you might not be able to appreciate their suffering and why dying in a hospital where a palliative care RN and Physician can assess them several times during a day as they adjust the meds is sometimes the better option. No one has a crystal ball to see in the future as to how much a patient will suffer as they die and there are limits to just killing the patient by OD'ing them on the home pain medications. When one of these patients is admitted, the physician or Palliative NP will assess and maybe switch meds to one which is done in a hospital rather than giving this responsibility to the family at home.

 

[triemal04]

That is a bold statement to make. Let's agree to disagree. I will respond further when I get off work.

Ironically, I just got done making a patient comfort measures only. If they do leave the hospital the expectation is that they will not return.

Please do. It may be enlightening, and I'll even promise to take a deep breath before I respond.

I don't think that you or Halothane understand how prevalent standardized forms for advance directives are becoming nationwide, who uses them, or what they actually mean.

In all the forms that I linked to in another thread (and all the ones that I didn't but can be found through the POLST website) one option is for a person to declare themself a "DNR with comfort measures only." Which means that they don't want life sustaining treatement. I think that you will agree that is what it means.

It does not neccasarily mean that the person is in the final stages of their life; it just means that should something happen they do not want life sustaining treatement and want to die naturally; hence why otherwise very healthy people will choose that option.

It doesn't mean that they will stop taking any medications that they are currently on, or that they can't choose to temporarily or permanently rescind it and start new treatements (such as for a UTI as was mentioned earlier).

What it means is that if that person becomes incapacitated their wishes for their treatement are known, and will be followed.

So there are situations where someone who is a "DNR with comfort measures only" will call 911 and WANT to be treated, as is their right.

There are situations where someone who is a "DNR with comfort measures only" will call and the needed treatement is something perfectly in line with their wishes.

There are situations where someone else will call 911 for the reasons I gave several times and the patient WILL NOT want to be treated, as is their right.

Is this getting clearer?

 

[Carlos Danger]

Please do. It may be enlightening, and I'll even promise to take a deep breath before I respond.

I don't think that you or Halothane understand how prevalent standardized forms for advance directives are becoming nationwide, who uses them, or what they actually mean.

Is this getting clearer?

Look man, I don't even know what you are talking about anymore. You are just rambling and repeating yourself and making baseless accusations about others not knowing what they are talking about. I really don't even see where you've contradicted anything I wrote.

Why not just drop it and have a beer or two before you give yourself a stroke.

 

[chaz90]

I've been trying to follow along in this thread, but I'm afraid I've lost all sense of what's going on in every direction.