Scenario: Can you actually treat this patient?

Clare said:
I really can't believe I am reading that - no, like, really. That's pretty horrendously disrespectful to the wishes of the patient. I would like to see where it says the family has a right to insist that you provide treatment that is not indicated (in this case, because the patient has refused it).

Surely whatever patient rights law gives the patient the option to make an advanced directive, and I'd bet it doesn't say "the family can overrule it". Therefore, by converse of same, surely that should also provide you with protection against not acting.



If the patient is competent by whatever definition of competency you use, then yes, they have the utmost right to refuse care and make an advanced directive. From the perspective of ambulance personnel, the patient would be refusing or making advanced choices regarding care that can be provided or facilitated by them. For example, in this situation, ambulance personnel can provide treatment for STEMI and cardiac arrest and facilitate transport for pPCI, all of which the patient refused (which by proxy, for cardiac arrest, is an advanced directive given he was not yet in cardiac arrest). I would be perfectly comfortable with discussing this with the patient and answering questions as it is something I know well. If they wanted to make an advanced directive for something "in the future" other than what is right infront of me then they need to discuss that with their GP or whomever. However, from the perspective of ambulance personnel, I am not referring to that.



I think the common assumption of implied consent the world over is that patients want life-sustaining treatment until proven otherwise.

So what you are saying is that in the United States, (a) an advanced directive can only be made to a doctor and not ambulance personnel or other healthcare providers and (b) that it must be in writing, oral directives are not acceptable? Is there a specific place where this is spelled out?

From what the other bloke wrote, it doesn't sound like an advanced directive actually protects what the pt wants because the family can show up and say "that doesn't matter, we want ...." and ambulance personnel will provide it regardless.

To me this makes absolutely no sense, because unless there is a specific provision within whatever charter or code or document of patients rights you operate under gives the family the ability to override what the patient has directed, then what they want has absolutely no bearing on anything at the end of the day. Of course what the family say must be taken into account, but the therapeutic relationship is between the patient and healthcare personnel (including ambulance personnel) and not the family (unless of course they have EPOA).
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In my state, the NOK can actually revoke a DNR on scene. And if the family member has a healthcare POA, even if the patient is adamant about being a DNR and has the appropriate paperwork, the POA can override that.
As for the base scenario in the OP... I honestly don't know what I'd do. I know I'd be calling Med Control right then and there, and probably initiate BLS care... There's no one good answer for this, especially since state laws vary so much.
 
A good example about advanced directives would be a personal example of one of our Grandparents:

When he's in the hospital in bad shape, he keeps wanting a DNR. He wants no care, he wants to die. The family usually tells him, "Hey, let's wait and talk about this tomorrow." But, nope, his mind is made up. He doesn't want to live anymore. He's in a lot of pain.

Then...he gets home, feels all right and wants to live. He sees his doctor for a checkup and wants to live because he's in good health. He decides that he wants to be resuscitated in the event that something happens.

The truth: He suffers from depression. It was very late onset in life. Only in the last few years. He takes medication for it. While he is alert to person, place, time and event during an emergency, most people don't realize that he is on a medication for depression and that he hasn't taken it at the appropriate or allotted time during the emergency. Most people would see the STEMI, but miss that he is also depressed, or see it as, "He's having a bad day because he is having a STEMI." While he may be AAOx4, he is in a compromised mental state, which needs to be fixed before such decisions should be made.

This is a true story and something we've honestly been dealing with recently.
 
Josh has a good example of the complexities.

Clare: part of the issue here is that in real life, things often aren't clear-cut. It's not unusual in (for example) the ICU setting for conflicting information to be available regarding a patient's wishes -- multiple family members, directives of various sorts and defensibility, the judgment of the treating team, etc. While these things are muddled through on a daily basis, when in doubt most people would err on the side of treating, since that's a mistake you'll get to make again. And in the typical prehospital setting, with providers of far less training, more chaotic circumstances, less time to reflect, and fewer resources available, this is even more true.

Again, state law varies, but typically EMS protocols do explicitly state something along the lines of "when in doubt, resuscitate." It's also common that efforts are made to simplify EMS care by limiting the number of documents we can honor -- many states have a single simplified DNR form that needs to be physically present for field crews to avoid resuscitation. That way we don't have to get out our spectacles and inspect ten different contradictory pieces of paper while CPR is going on, never mind any additional opinions from the peanut gallery.

I agree that if a clearly-valid directive exists refusing care, it should not be possible to override that. The dilemma arises if the directive is called into question -- i.e. you have family saying, "No, that's not right, he signed that ages ago but lately he's been saying he wants everything done."
 
Handsome Robb said:
@ERDoc with that line of thinking does that not make DNRs that are invoked on the ER and ICU every day across the country invalid since the patient in those circumstances is also in extremis and cannot discuss it "ahead of time, in the appropriate setting where proper thought and discussion can be had."

I agree that in ideal circumstances this conversation should be had in a setting without pressure and with unlimited amounts of time to discuss and confirm exactly what the patient is requesting however as an ER Doc I know that you're fully aware that this isn't always a luxury granted to us in emergency medicine.

Not trying to be argumentative, just bringing up a point and something I've witnessed happen in the ER more than a few times.
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You bring up a good point. I have had the "how much do you want done?" conversation with many pts that are circling the drain. In that case though, I was there are personally had the conversation with the pt and know exactly what was discussed. In the case where a crew calls up, I was not there and do not know exactly what was discussed. If they are going to call and place the responsibility for making the decision on me, then I am going to err on the side of caution and say work it since I never interacted with the pt. As for the legal issues, I doubt you will find much precedence for a case like this so it will basically be up to the jury to decide your fate. Who wants to roll those dice in the US? Ideally, we should not be practicing medicine based on the threat of legal action, but here in the US, where anyone can sue anyone and you can pay out millions of dollars because your hot coffee is, well, hot, it's not a chance I want to take. I have a wife, kids, house and career that I would like to keep.
 
ERDoc said:
Who wants to roll those dice in the US? Ideally, we should not be practicing medicine based on the threat of legal action, but here in the US, where anyone can sue anyone and you can pay out millions of dollars because your hot coffee is, well, hot, it's not a chance I want to take. I have a wife, kids, house and career that I would like to keep.
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The cost of doing so and significant legal protections for healthcare professionals (including ambulance personnel) just make this simply so nearly impossible that in all practical reality it is, to my knowledge, impossible, to achieve this here.

You would need to file suit for exemplary damages, for example, for lost earnings of the person who was not resuscitated, and the only real way you could do this would be to prove gross negligence on the part of ambulance personnel. The law regarding competency and advanced directives and patient choice and such is so in favour of the patient (and by proxy, the ambulance personnel) that it would be fighting such an up hill battle I seriously doubt you would find a lawyer willing to support you. You could represent yourself against the ambulance personnel involved by calling them to a civil dispute at the small claims tribunal but the cap is something like $5,000 and the ambulance service and the union would go after this like a house on fire to protect you.

It is legally not possible to have the ambulance service named in a suit for damages (given our comprehensive medical misadventure compensation legislation prohibits this) and a quick search of judicial decisions online from the Ministry of Justice from 2003 onwards reveals that at no time has the ambulance service been sought for exemplary damages either.

I guess different countries are different and that's fine, but I guess that I am lucky that I never have to worry about anything like this ever and I know that if I do cause harm to somebody by accident that there is a comprehensive system set up to not only treat and look after that person and assist them in whatever they need for the rest of their lives but to also protect me from being named in some million dollar American TV style lawsuit.
 
You have no idea how lucky you are. EMS agencies are constantly named in suits here. There is no protection. We (ER and EMS) are required by law to see/treat everyone without expectation of payment, yet have no protection from any lawsuits, legitimate or frivolous. Even in places that have tried to add some degree of protection, the lawyers find ways around it.
 
In theory, a system that relies on the threat of civil judgements to enforce competent decision-making is preferable to one where regulation specifies every action and criminal prosecution is the punishment for non-compliance.

In reality, we have unfortunately drifted to a place where we have to deal with the worst aspects of both approaches.
 
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Who called us back a second time? Yes the (compitent) patient has a right to refuse treatment and/or transport, they also have the right at any time to invalidate a DNR order by simply telling me to ignore it. Also, my protocol says that even in the presence of a properly filled out and signed DNR/POLST/AHCD etc if any family member on scene objects to withholding CPR, we are to immediately initiate BLS measures and contact medical control.

So for our hypothetical STEMI patient who AMA'd earlier, if we get re-dispatched, either they decided that yeah, they do want treatment and called before coding, or family wants treatment and called, both cases would mean beginning resuscitation even with a paper DNR present. Now if a SNF staff or member of the public called, if the DNR is present, well then we follow the DNR
 
That would have been part of my conversation with medical direction before departing the scene: "so doc, what happens if this guy dies in front of me? CPR or no?"

It would be unethical to resuscitate.

it would be arguable in court or before a professional board that you should have resuscitated.
 
To paraphrase my instructor, in the US, as an EMS provider, it's not a question of IF, but of WHEN and HOW OFTEN you get dragged into court.
 
Clare, the whole idea of an advanced directive, around here anyways, is to clear up the patients wishes, with informed consent, in writing, with a witness and a physician, BEFORE they code. When executed properly, a grieving family member can be shown the paperwork, reminded of their loved one's wishes, and resuscitation can be stopped or not initiated in the first place. In my short career I have had to proceed with contacting on line med control once to talk with the family and once called the PCP. In the pre hospital setting I have never worked a code or transported a pt with a DNR but certainly family members (usually only one) often try to get us to work it.
 
Section 823, page 4, section F

And here is a local protocol for northern California, which states if family says work it, start BLS and contact mes control. Like I said the one time I had to do this the physician on the phone was able to convince the family to stop.

FWIW I don't think anybody here disagrees with you about ethics or patient autonomy, its just that for most of us our hands are tied. Also, I don't think this situation occurs all too often that we are transporting DNRs every day.
 

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Patient refusal of treatment during signs and symptoms is acceptable, let them be and leave. If they refuse to sign an AMA, contact your medical director. If they were still responsive during a MI and said "no treatment", let them be and leave. Same contact with your medical director. If you are still there and "they hit the floor and are unresponsive", your next response is dictated by a valid DNR or POLST and Implied Consent for treatment direction. Contact your medical director. There's no reason to make these decisions on your own. Keep your decision process simple. The only issue I see is the when the patient verbally informs you "no treatment" during the first two scenarios, does the patient present cognitive knowledge of the risks of " no treatment"? How many "jumpers" have thought " this was a bad idea", on the way down. And, I should have listened to that emergency responder.
Just thinking.....Jed.
 
Jed Bishop said:
How many "jumpers" have thought " this was a bad idea", on the way down. And, I should have listened to that emergency responder.
Just thinking.....Jed.
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According to some research, most of them.
 
In my state, implied consent would be valid here unless they have a DNR. Only recently were we even allowed to follow DNR's for codes. We were taught that if there is any question of whether or not you should treat a code, treat it.
 
Noncreative said:
Well, it is with a conscious and competent patient. But without a valid DNR, you're leaving yourself open to abandonment.
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Citation please.

stethoscope said:
In my state, implied consent would be valid here unless they have a DNR. Only recently were we even allowed to follow DNR's for codes. We were taught that if there is any question of whether or not you should treat a code, treat it.
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Also citation. If people were not honoring DNRs that would be a serious issue.

Also, I'm not sure how many times I can say this and I mean this more generally, but the patient's wishes need to be respected. Sometimes things happen too fast for advanced directives to be properly completed but the patient has made his or her wishes clear. While it is fine to start efforts in an ambiguous situation, it should be someone's priority to make contact with medical control to get cessation orders. There is not a conspiracy of family members killing their loved ones and then saying "oh they had a DNR I just can't find it" and EMS needs to stop pretending that this exists. It's disrespectful to both the patient and the family.
 
Handsome Robb said:
A discussion in another thread as well as a discussion I had with my last trainee and another coworker gave me the idea for this thread. I will give you my opinion on the matter after others have chimed in.

You're on scene of a patient who is awake, alert, oriented, ambulatory, not intoxicated, very capable of caring for themselves, not suicidal/homicidal and is able to understand and reiterate everything that is explained to them including the gravity of their situation, the risks associated with refusing care and transport and instructions that are provided to them. There is a witness on scene who is competent as well and signs the AMA form as a witness.

This theoretical patient is having chest pain and either they called or a family member called, doesn't really matter.

The 12-lead shows a massive anterior STEMI, their vitals are not terrible but trending towards hemodynamic instability. You explain everything to the patient and tell them they need to go to the hospital for emergent PCI however they adamantly refuse stating "if it's my time it's my time." They do not want to go with you or POV and adamantly state they do not want medical attention of any kind and do not want to be resuscitated however they do not have a signed DNR or POLST.

As you're leaving you hear a thud and turn around to see the patient ago all on the living room floor. You check and they are pulseless. Can you treat this patient? They're unresponsive now so implied consent seems like it's cut and dry however it's the same condition you were just assessing them for that cause the cardiac arrest and when they were fully capable of making decisions they adamantly refused treatment and transport and acknowledged the fact that this may very well kill them. They stated they do not want to be resuscitated and do not want any help.

Tell me what you think, keep it civil and support your answers with why not just "mongo do this!" Ready, set, GO!
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Without reading any of the replies, I'm going to say without question I would begin CPR immediately. I would assume a conflicting medical problem altered the mental status of this man. There is no way to know for sure. How was his cardiac output? How strong was his pulse? OX? BGL? History of diabetes? Was the clot sudden or gradual?
I'm sorry but without a proper SAMPLE history, I can't offer a definitive answer
 
Assume altered mental status? Differentiating between sudden and gradual clots? What?

It says in the first sentence of the scenario:
You're on scene of a patient who is awake, alert, oriented, ambulatory, not intoxicated, very capable of caring for themselves, not suicidal/homicidal and is able to understand and reiterate everything that is explained to them including the gravity of their situation, the risks associated with refusing care and transport and instructions that are provided to them. There is a witness on scene who is competent as well and signs the AMA form as a witness.

This is clearly meant to be a discussion about consent. Either start reading the words in front of you or stop trolling us.
 
Flying said:
Assume altered mental status? Differentiating between sudden and gradual clots? What?

It says in the first sentence of the scenario:
You're on scene of a patient who is awake, alert, oriented, ambulatory, not intoxicated, very capable of caring for themselves, not suicidal/homicidal and is able to understand and reiterate everything that is explained to them including the gravity of their situation, the risks associated with refusing care and transport and instructions that are provided to them. There is a witness on scene who is competent as well and signs the AMA form as a witness.

This is clearly meant to be a discussion about consent. Either start reading the words in front of you or stop trolling us.
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This just simply doesn't make sense considering I would never trust someone else's judgement over my own.
 
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