EMS discontinuing life support.

[Seirende]

Probably the single most stressful stretch of time over my thus far short career was sitting around waiting for a hospital discharge call. I was paired with a CC medic for training and he got assigned an upcoming hospice discharge. Pt had a degenerative terminal disease, was vent-dependent, responsive to painful stimuli, on a morphine drip, and was going home from the ED under hospice care. Oh, and the family wanted the CC medic to DC the vent upon arrival at the house.

The CC medic was surprised and uncomfortable, his partner was uncomfortable, and I was burning a hole in my stomach lining over the next few hours trying to do the ethical math, so to speak. I decided that I agree that discontinuing life-sustaining measures can be appropriate in the face of end-stage terminal disease. However, I think that while having EMS providers be the agents for this is not necessarily wrong, it's not ideal. I can't name many pros and cons, and it's probable that the sensation of gut-wrenching discomfort in this particular situation may be leading to prejudice in my reasoning.

Obviously, this is a very rare scenario for most of us. I found myself very unprepared. My eventual reaction was that it was ethically permissible to aid something that I don't disagree with, but in a future more practical sense, I don't know how I would have dealt with having the CC medic's role.

In this case, the family changed their mind at the last minute and decided to wait a bit longer. We left them the service's vent and I, for one, was greatly relieved for no rational reason.

How would the readers of this thread handle an assignment similar to the above described? What do you think would be the best way for the medical system to handle a case of a patient on life support who(se family) wants (him or her) to be removed from said support at home?

 

[NomadicMedic]

Have a hospice nurse on site at the home d/c the vent.

 

[ERDoc]

That was a pretty crappy set up by hospice. Like DE said, it should have been done by a hospice nurse. You are basically talking about a terminal wean which is not in the scope of practice for EMS.

 

[Tigger]

While I have no qualms with hospice patients wishing to be removed from life support, I am not sure that is an EMS providers role either. I think I would want hospice to come out and make sure it was done properly.

 

[Kevinf]

Agreed, I'm not going to simply walk into someone's life for 10 minutes and make a choice to end it. This needs to be handled by their long term caregivers.

 

[Seirende]

What would y'all do if assigned this call? Refuse to be responsible for the actual vent d/c? Request that a qualified nurse handle the procedure? It seems reasonable for EMS to handle the transport and transfer care to an RN once at the residence, just like any other hospice discharge.

That was a pretty crappy set up by hospice. Like DE said, it should have been done by a hospice nurse. You are basically talking about a terminal wean which is not in the scope of practice for EMS.

I'd assumed that the CC medic was educated to a level of competency in removing the vent of a vent-dependent patient, but it does seem unlikely for that to be a part of any EMS oriented curriculum. More knowledgeable practitioners can enlighten me if I'm off base. Out of curiosity, what are the considerations for a terminal wean as opposed to a "regular" wean?

To be fair to the hospice, there was a nurse or two present, at least; it wasn't just EMS and the family.

 

[Tigger]

We take people home fairly frequently. Once we get them as comfortable as possible we leave, and then hospice shows up eventually. If it was a vent transfer we would need hospice to be there with their own vent prior to departing.

 

[Summit]

I'd assumed that the CC medic was educated to a level of competency in removing the vent of a vent-dependent patient, but it does seem unlikely for that to be a part of any EMS oriented curriculum.

Withdrawal of care is a very important part of Critical Care. Critical Care RNs do it regularly.Critical Care Paramedics rarely that experience unless they were also an ICU or Hospice RN.

Anyone can disconnect a vent. Withdrawal of care and a terminal wean is an art of sorts.

To be fair to the hospice, there was a nurse or two present, at least; it wasn't just EMS and the family.

What were they doing?

 

[ERDoc]

What would y'all do if assigned this call? Refuse to be responsible for the actual vent d/c? Request that a qualified nurse handle the procedure? It seems reasonable for EMS to handle the transport and transfer care to an RN once at the residence, just like any other hospice discharge.



I'd assumed that the CC medic was educated to a level of competency in removing the vent of a vent-dependent patient, but it does seem unlikely for that to be a part of any EMS oriented curriculum. More knowledgeable practitioners can enlighten me if I'm off base. Out of curiosity, what are the considerations for a terminal wean as opposed to a "regular" wean?

To be fair to the hospice, there was a nurse or two present, at least; it wasn't just EMS and the family.

If there were hospice nurses there then this transport would be totally appropriate. You are turning the care over to the hospice nurses, who are by far the most appropriate people to handle this. Even if a CC medic has been trained for removing vents, they likely do not have the experience to take care of a situation like this. Hospice/end of life care should be handled by someone who has experience with it.

 

[Gurby]

Nopenopenopenopenopenopenope.

I would plead with them to wait until the hospice nurse gets there, call medical control, etc. I'm definitely not going to be the one to personally pull the plug.

 

[Summit]

Nopenopenopenopenopenopenope.

I would plead with them to wait until the hospice nurse gets there, call medical control, etc. I'm definitely not going to be the one to personally pull the plug.

There is no need to plead. You make a good case for why: that hospice can support the patient's comfort in the withdrawal of care in necessary ways that you cannot .

 

[Seirende]

What were they doing?

I'm not sure, to be honest. Since the vent was continued after all, and because I was only marginally involved, I don't know how active they would have been in supervising the procedure.

If there were hospice nurses there then this transport would be totally appropriate. You are turning the care over to the hospice nurses, who are by far the most appropriate people to handle this. Even if a CC medic has been trained for removing vents, they likely do not have the experience to take care of a situation like this. Hospice/end of life care should be handled by someone who has experience with it.

Setting aside the question of scope for the moment (because I'm not familiar with any scope beyond my own), what I'm hearing is that it is definitely not medically appropriate for an EMS provider to d/c life support without direct supervision, but it may be medically appropriate for EMS to assist with discontinuing life support under the direct supervision of a hospice nurse.

So far, so good. What about the question of providers who are deeply uncomfortable with the idea of being hands-on with discontinuing life support, "personally pulling the plug," as @Gurby said. Would it be appropriate to defer the call? Or should we be as prepared to handle this as we would any other uncomfortable aspect of the job? The only difference that I can think of off the top of my head is that this does not seem inherent to the field of paramedicine, as notifying family of a patient's unexpected death would seem inherent.

 

[Gurby]

I would have no qualms ethically/morally with "pulling the plug". I think it's great that the family is able to let go and isn't forcing every possible intervention on the patient against their wishes, which seems to happen all the time. I just have never personally done it, have no protocol for it, etc. I watched a terminal wean from start to finish during my medic hospital time and it was a pretty interesting experience, that involved a lot of morphine as I recall...

How the heck do I document this anyways? "On arrival, moved patient to bed: rails x2. Report given and care transferred to family member. Disconnected vent per request of family. P1 clear."...

I wouldn't be assisting a hospice nurse either, without contacting medical control. What am I going to do, give morphine? Probably would get me investigated by the DEA or something.

This would be an easy situation to deal with. We arrive on scene, family wants us to disconnect the vent. I tell them no, hold on while I call up my medical director and see what he wants me to do. If they have a hospice nurse there, I turn over care to them and they can do what they want.

 

[Seirende]

I don't have any ethical or moral qualms either. I just really, really, don't want to have to be intimately involved. That's the core of my question, I suppose.

To be clear, this wasn't a scenario where we got on scene and then the family asked for the vent to be discontinued. The initial phone call from dispatch included that information.

 

[Tigger]

I would have no qualms ethically/morally with "pulling the plug". I think it's great that the family is able to let go and isn't forcing every possible intervention on the patient against their wishes, which seems to happen all the time. I just have never personally done it, have no protocol for it, etc. I watched a terminal wean from start to finish during my medic hospital time and it was a pretty interesting experience, that involved a lot of morphine as I recall...

How the heck do I document this anyways? "On arrival, moved patient to bed: rails x2. Report given and care transferred to family member. Disconnected vent per request of family. P1 clear."...

I wouldn't be assisting a hospice nurse either, without contacting medical control. What am I going to do, give morphine? Probably would get me investigated by the DEA or something.

This would be an easy situation to deal with. We arrive on scene, family wants us to disconnect the vent. I tell them no, hold on while I call up my medical director and see what he wants me to do. If they have a hospice nurse there, I turn over care to them and they can do what they want.

We have no issue with contracting medical control for hospice care. Even if hospice is not on scene, so long as everyone is on the same page the docs are all for it. We're actually attempting to contract with a local hospice program for after hours response, it takes them a long time to get to patients at night.

 

[firecoins]

That doesn't get transported back. Its beyond our scope. They have to have their own vent at the residence and hospice takes care of that. If thats not set up, they don't get transported.

 

[usalsfyre]

There's this much discomfort over end-of-life care....Jimeny Christmas....

1. Most medic units don't have the orders or meds for appropriate terminal weans. Most CCT units should.

2. Terminal weans are not easy, it's a balance between treating air hunger/discomfort and outright killing the patient.

3. The DEA doesn't give a $hit as long as the appropriate documentation is completed, it's literally no different than giving a med to any other patient

4. Everybody thinks community paramedic stuff is cool? This is community paramedic type stuff. It's not high speed/low drag, it's actually being a healthcare provider