saving lives?

[JJR512]

Who the heck said anything about a resuscitated patient?

I did. It was part of an example scenario I used several posts back.

About the hospice patient, well I think I already mentioned hospice patients, too. More to that point, around here, it is my understanding that hospice patients are almost always DNR. So that patient probably isn't going to get transported.

There are always exceptions, no argument about that.

 

[Aidey]

DNR or not has nothing to do with it, the hypothetical patient isnt in arrest.

 

[JJR512]

DNR or not has nothing to do with it, the hypothetical patient isnt in arrest.

Well the one I was talking about was, so whatever. Look, how much further do you want to continue this stupid pointless back-and-forth? Because I will keep playing. But I'd much rather not keep cluttering up this thread with this ********; I'd much rather see more about the intended topic of discussion.

 

[Aidey]

Ok, back on topic then.

You are called for a patient on Hospice, end stage cancer with mets everywhere, given days to live by Hospice, wants to die at home. When the patient's mental status starts to decline the family panics and calls 911.

So what do we as EMS providers do? Do we try and follow the patient's wishes to stay out of the hospital or do we transport and let the doc at the ER take it from there? What is the role of EMS in this patient's case?

 

[TacoMEDIC]

Ok, back on topic then.

You are called for a patient on Hospice, end stage cancer with mets everywhere, given days to live by Hospice, wants to die at home. When the patient's mental status starts to decline the family panics and calls 911.

So what do we as EMS providers do? Do we try and follow the patient's wishes to stay out of the hospital or do we transport and let the doc at the ER take it from there?

Our protocol indicates that the family may make the decision in the presence of EMS. Base Station contact is helpful in these scenerios. It never hurts to spread liability to higher level medical professionals.

 

[Aidey]

That doesn't actually answer the question, remember family called.

Do you transport based off of their panicked decision to call 911 or do you discuss the situation and find out if transport is truly indicated or if the problem can be solved another way?

Do you sit down, talk to the family about why they are panicked? Spend time explaining what is expected when someone is near death, maybe call hospice if they are involved or the pts primary? Do you offer any reassurance, or offer to help them with something they are too overwhelmed to do?

 

[JJR512]

I don't know what "mets" are but barring them being anything that would change my initial opinion, my feeling is that the exact scenario currently being discussed does not call for transport. I would discuss the situation with the family, as posed in the follow-up question. If the panic can be calmed, I would most definitely get a refusal signed. If the family is insistent on transportation, though, I would probably consult medical direction first. Since I'm unexperienced in these kinds of situations, consulting seems like a wise course of action.

If the family insists on transportation, I really have no idea what would happen. The hospice facility staff may try to show me advanced directives or a living will or something to that effect, but the only document that I am legally allowed to interpret and use as a means to stop providing care is a DNR. This patient in the currently-posed hypothetical situation isn't in need of resuscitation, though. And a DNR doesn't say anything about transporting. So if, due to being unsure of the situation, I do a consult, if I tell the doc in the box that the hospice has these documents, I don't really know what medical direction can do with that info. I can't tell if those documents are legitimate, so I can't tell medical direction that they're legit. I don't know if medical direction would want to talk to the hospice staff.

I have a sneaking suspicion, though, that medical direction would just take the easy way out, err on the side of caution (meaning making sure they're covering their asses), and order a transport.

 

[firetender]

I thought the way was to help people. At the very least "do no harm." ...why do we go through the motions?

Is it better to live well for 2 years or suffer for 3 or 4? ...the industrialization... without consideration or response...the only outcome is normal or death. There is no middle ground...Costing a family tens of thousands of dollars they didn't have

I see it as questions that need to be reconciled...
protocol driven medicine is a wrong turn...Helping all of your patients to the best of your knowledge and ability is medicine...What justifies the quest of making things easier on ourselves when it doesn't serve those who came to us for help?

why continue to do what we know won't help?

Vene, you're lucky you're over there and not HERE! If you think you're hobbled now try adding insurance, co-payments Medi this that and the other, and out of every nook and crannie is waiting a lawyer poised to pounce as soon as you slip your scalpel! I'm talking PURELY money-driven. I suspect you still have a semblance of sanity over there!

Helping all of your patients to the best of your knowledge and ability is medicine

Oops! that's where you missed the boat. Medicine is all about making it look like we know what we're doing and eventually can cure everything. Medicine, were it to allow its practitioners to do as you say would spend equal time on preparation for death as it would on diagnostics. The problem with medicine is it largely denies death.

The "We're doing everything we can" part is accurate. It's doing, doing, doing, regardless.

People want the best that money can buy and believe that going into debt is worth the gamble, figuring the more it costs the better the odds of success. They blindly say "Yes, yes yes!" when what they should be asking is, "Really, Doc...is the extra time gonna be worth living?"

And no Doctor will tell the truth because NO DOCTOR HAS THE ANSWER. None of it is up to us, so we're in a bind.

The practitioners get told the next big thing will make a difference, so they tell their patients, "We beleive this might make a difference."

The truth is, on some people it might and others it might kill. Our goal is not to lessen the pain and suffering of our failures, it's to produce an effect in the successes that does just a bit better than sugar pills.

I believe the poster who said you're butt is more likely to be twisted around since you didn't go into this naive.

...I see it as questions that need to be reconciled...why continue to do what we know won't help?

BINGO! it's something you and you alone must come to terms with.

This is harsh, but if you are aware that something you've been told to administer or recommend will prolong suffering, then you have to make a choice that you can live with. One such choice could very well be, "I'll do what I'm told, learn as best I can how to be able to judge for myself better, and then work toward beang able to make more autonomous decicions as quickly as possible."

Vene, you, in particular are in a business where pain and suffering are often considered acceptable collateral damage in pursuit of knowledge.

 

[firetender]

...almost forgot...

The real matter is why?

Now, how does this apply to EMS? It doesn't, really.

It's a human thing about moral and logistical choices. It's about struggling in conflicts between your head and your heart. It's about being in extreme circumstances where lives hang in the balance and you have to make quick choices for people who can't for themselves and sometimes they are wrong. It's about circumstances where you may actually encounter the handiwork of your choices, brain dead in Neuro.

These are things we NEVER encounter in EMS.

 

[Aidey]

Now, how does this apply to EMS? It doesn't, really.

It's a human thing about moral and logistical choices. It's about struggling in conflicts between your head and your heart. It's about being in extreme circumstances where lives hang in the balance and you have to make quick choices for people who can't for themselves and sometimes they are wrong. It's about circumstances where you may actually encounter the handiwork of your choices, brain dead in Neuro.

These are things we NEVER encounter in EMS.

Not necessarily true. Where I live we have a true rehab hospital*, and it is entirely possible you will transport a former patient to/from there, be it the broken hip or the near drowning.


* As in it is an actual hospital, not just a SNF that has rehab available.


Edit: You're being sarcastic aren't you?

 

[firetender]

Edit: You're being sarcastic aren't you?

I'm from NY...it's a genetic defect!

 

[Aidey]

It took me a min, becuase I could see someone trying to argue that we don't have to live with the consequences of our decisions in the field. Is it sad I could see someone arguing that seriously? Don't be offended I thought you were, I woke up early and didn't get a nap.

 

[JJR512]

It took me a min, becuase I could see someone trying to argue that we don't have to live with the consequences of our decisions in the field. Is it sad I could see someone arguing that seriously?

Yes. Well, perhaps it might be nicer to say that it's realistic to understand that some providers could argue that, and that is what's sad.

 

[Veneficus]

Vene, you're lucky you're over there and not HERE! If you think you're hobbled now try adding insurance, co-payments Medi this that and the other, and out of every nook and crannie is waiting a lawyer poised to pounce as soon as you slip your scalpel! I'm talking PURELY money-driven. I suspect you still have a semblance of sanity over there!.

Don't bet on it. Not all the systems here are social. Here you are required to have insurance. Which just like everywhere else wants to make money. The gov covers a rather sparce policy for those out of work. If something is not covered by insurance, the person pays out of pocket. If they can afford it. There is a limited charity budget and when it runs out it is gone for the year. On the lower plans you can see a GP anytime, bt even when referred to say, a nerologist, it can take months to get an appointment. Obviously the better your plan (aka the more you pay) the better your service. Still something is better than nothing. In special circumstances, a provider can make a case to the ministry of health to cover costs beyond what insurance would pay, but it is not likely to succeed. Providers also have taken to writing directly to various companies asking for charity direct. Which works better than the Ministry.

But the finer points of healthcare costs have already been argued on this forum, and I really can't take anymore pseudoeducated decisions based on half truths and political rhetoric on both sides.

Oops! that's where you missed the boat. Medicine is all about making it look like we know what we're doing and eventually can cure everything. Medicine, were it to allow its practitioners to do as you say would spend equal time on preparation for death as it would on diagnostics. The problem with medicine is it largely denies death.!.

yea, that is the part I can't get my head around. A bunch of really smart people pretending it doesn't exist. Could almost be a relious order.

The "We're doing everything we can" part is accurate. It's doing, doing, doing, regardless.

"You've done it I exclaimed with a scream and a taunt, it's just what I asked for, but not what I want."

People want the best that money can buy and believe that going into debt is worth the gamble, figuring the more it costs the better the odds of success. They blindly say "Yes, yes yes!" when what they should be asking is, "Really, Doc...is the extra time gonna be worth living?"

I think it is medical providers that pushed this and the patients caught on.

When somebody asks "what does this mean?" we often tell them about the science of it. Most people don't care, they want to know if they will be able to go back to work, walk, see, whatever. I always try to make a point of figuring out their concerns. It is within my power to answer honestly, and they seem to appreciate it more than a patho lecture.

The practitioners get told the next big thing will make a difference, so they tell their patients, "We beleive this might make a difference."

I think it is hope of the providers. Otherwise it would make updating cpr sort of useless.

The truth is, on some people it might and others it might kill. Our goal is not to lessen the pain and suffering of our failures, it's to produce an effect in the successes that does just a bit better than sugar pills.

Hopefully a bit more than sugar

I believe the poster who said you're butt is more likely to be twisted around since you didn't go into this naive.

Perhaps I was expecting more.

 

[CAOX3]

I think healthcare is driven by its customers, if everyone wanted to die gracefully at home it would have gone in a different direction. People want one more day to spend with their loved ones, to see their children grow up, get married.

Its ultimately their decision, I don't see a problem with that.

We in the the health care field know, we holds are breath when a loved one admits a diagnosis to us, its like a curse sometimes because we know what the eventual out come will be.

We spend are entire lives planning for the future, forming bonds and loving your children, wives mothers and fathers, when a doctor walks through the door and states it isn't going to end like we planned, we as people don't want to accept that so we fight to continue on and that's our choice. The quality of that life isn't or decision to make, If that's their wish that's what we do.

That's why on scene I try not to think or let my personal opinion s get in the way if their sick and they arrest sure I know the for the most part what the final outcome is going to be but its their choice to spend one day in icu so they can sit with their loved ones, whatever their capacity then we do it, health care is about the patients wishes not the providers.

 

[Aidey]

I don't think the issue is so black and white we can pin the blame on doctors or patients. I think the situation is incredibly more complicated than that, a view which I think is supported by some of the end of life research that has been done.

With patients things like education, religion, current social life (family, job) all impact the decisions they make. Doctors, as much as no one wants to admit it are also affected by the same things. I read the results of a study recently that showed doctors who identified as religious tended to be more conservative with end of life care. Specifically in the conversations they have and how aggressively they medicate patients with medications that may result in the pt dying sooner, like high dose morphine.

I know we run into patients who have orders for palliative care, but with CPR. I've been told that this is a common occurrence in some religious patients because they view not doing CPR as hastening death.

I can also imagine that education levels of the patient play a huge role in how care goes. If a doctor is dealing with a cancer patient from a family where none of them have higher than an 8th grade education. What is easier for the doctor, educating the family and patient to the point they can make informed decisions, or for the doc just to say "this is what we should do" and do it?

And googling is enough of an issue for its own thread. I'm a huge advocate of education, but when someone becomes convinced that The Internet knows more than any doctor out there there is officially a problem.*

And really, there is always the liability issue.

Case in point.

Mid 60's male, SNF. Severe cerebral palsy, paperwork states that the pt has the mental status of a toddler. Pt has multiple ongoing medical problems. The pt develops a fever, the staff checks it, gives tylenol and calls the patients guardian to let them know what is going on. The patient's guardianship is through a hired service, he has no next of kin or people to notify on file. The guardian tells the facility to do whatever they think is best. Facility calls 911.

We get there, the facility is like "yeah we called cause the guardian said we should do whatever". The patient's fever responded to the tylenol, and he is asleep when he get there, not in any apparent distress.The pt has comfort care orders stating no transport unless they have comfort issues that can't be met out of hospital. The patient is in a SNF, and under the care of the facility doctor. The staff have the ability to call the doc or whomever is on call and get orders.

We talk to the staff, who is ok with the patient staying. We get a hold of the guardian who after being read the patient's advanced directive is ok with the patient staying as long as she isn't the one making the decision (which makes me wonder what the heck good does the patient having a guardian do?). Only thing left is to call med control to sign off on the whole thing. Med control orders transport.

Straight from the doctor's mouth, she was concerned about the liability of not transporting.

WTF. Seriously WTF. It doesn't make any sense to me. The system was actually working, and she threw a huge wrench in it becuase of concerns about not transporting a patient who had a signed order stating they didn't want transport, and was able to receive completely appropriate care where he was.

It needs to stop. I swear when I'm old I am having an advanced directive written up that expressly states do not transport, and if you do it will be considered kidnapping.



*So If you go to the ER for a rash, and the doc checks you out and sends you home, don't call the ambulance 30 minutes later because you think you have the plague thanks to google.

 

[Veneficus]

I don't think the issue is so black and white we can pin the blame on doctors or patients. I think the situation is incredibly more complicated than that, a view which I think is supported by some of the end of life research that has been done. .

Here is the problem, in order to pass to the 3rd year of school here, a student must take a palliative care class and clinical.

But the older physicians have not had it. They are also very set in their ways. Which includes 10's if not 100's of grading and staging charts (everything from COPD to various genetic disorders) and the treatments that go with them.

If the patient is x on scale y, perform such and such treatments. It doesn't require a doctor to do that. Infact I bet I can get any idiot off the street to do it.

With patients things like education, religion, current social life (family, job) all impact the decisions they make. Doctors, as much as no one wants to admit it are also affected by the same things. I read the results of a study recently that showed doctors who identified as religious tended to be more conservative with end of life care. Specifically in the conversations they have and how aggressively they medicate patients with medications that may result in the pt dying sooner, like high dose morphine..

In my opinion physicians who let their religion influence their decisions should lose their license immediately. There is absolutely no room for imposing arcane values on patients.

I know we run into patients who have orders for palliative care, but with CPR. I've been told that this is a common occurrence in some religious patients because they view not doing CPR as hastening death.

I am sorry, I know you are not advocating it, but that sounds absolutely stupid. Religion is the providence of fools. Made for the weak minded. I am afraid to think of what is next.

I can also imagine that education levels of the patient play a huge role in how care goes. If a doctor is dealing with a cancer patient from a family where none of them have higher than an 8th grade education. What is easier for the doctor, educating the family and patient to the point they can make informed decisions, or for the doc just to say "this is what we should do" and do it?

I guess it has just been pounded into my head over the last few years that it is the responsibility of the doctor to educate the patients.

The dean of our school often says "many people have medical degrees, few will ever be doctors."

I buy that 100%. Perhaps patients should stop going to see medical scientists.

And googling is enough of an issue for its own thread. I'm a huge advocate of education, but when someone becomes convinced that The Internet knows more than any doctor out there there is officially a problem.*

That is only going to get worse as the time goes on. But it just leads to doctor shopping. Eventually they will find one that gives them what they want. Not really too different from drug seekers really.

And really, there is always the liability issue.

I think this is a very weak excuse. I also think medical scientists (not to be confused with doctors again) did this to themselves. They created and wrote down the decision trees, the scales, and scores. They basically carved into stone what each patient should receive instead of listing what might be done.

In the effort to create "evidence" based medicine, medical professionals have basically tied their own hands. If the patient doesn't fit the protocol, they are truly at a loss, they will be put into the protocol and if it doesn't help or actually hurts, everyone will say they played by the book.

Truly, we should give up educating physicians, we should just develop protocols and give them to lawyers and eliminate the physician entirely. After all, a middleman between the sick and a lawyer really doesn't add any value.

 

[MrBrown]

IPain control...eh...who really cares. Nice, but they can wait, suffering for 20 minutes isn't that bad, they aren't going to die.

Brown hopes you don't treat him, his family or anybody he cares about or does not wish unjustified suffering upon.

 

[firetender]

Follow the Money!

I think the situation is incredibly more complicated than that....

A-(wo)men, Sister

The deeper I get into my own explorations into this, the more I hear these voices in my head, articulating things that the Therapy Manufactureers (without specifying BigPharma, of course!) would say if they were honest:

"Well, we came up with this. It took care of that. In order for us to take care of the other, we really need you to USE a lot of this.

Why, you ask?

Because with the money we make by you using this, (on everyone who falls near the horseshoe pin) we can develop something to combat the other, AND build another medical school so we have a lot more of you distributing this and the other others that we come up with.

Don't worry though, you really don't have to sell us. We'll take care of that by making sure that they, check with you to see if **** can releive them of one of the many niggling symptoms of being alive.

Remember, we're empowering you to handle the 44 Magnums, but they're indoor weapons. Outside we make sure they buy all the .22s and .38s they can shoot at their lower level ailments. See how slickly we've also drawn a line?

Because once someone needs testing to protect you and us from a lawsuit, they come to a box filled with diagnostics created by us so you have data supporting giving them more of this to treat that.

See how IT works? If we get them to buy into us, they go to you and we'll ALL make a living. Actually, only one of us will get rich. You will get burned out handling their requests and distributing our goods.

But look at how many people we keep employed; Our financial futures are assured by the endless loop we reflect; pitting hope against hope.

Don't be so selfish!"

 

[JJR512]

...Med control orders transport.

Straight from the doctor's mouth, she was concerned about the liability of not transporting.

WTF.

This is exactly why I added the final paragraph to my most recent reply. Just as it happened to you, I suspect it might happen in that hypothetical scenario you posed.