Really most sincerely dead.

[Veneficus]

I had an interesting experience yesterday.

I was part of the first randomized testing group for a practical exam being developed for doctors as part of a residency selection process. (place must remain anonymous)

But it basically is a preemployment test.

While officially I cannot discuss specifics, (NDA) I want to talk about 2 things that I now think need to be added to the paramedic practical.

1. Telling a family member that their loved one is dead.

2. Telling a family member their loved one is terminal.

Now I know many do not think that is their job. But I can tell you it is only a matter of time before you have to do #1.

It falls under the part of your job description that reads: "all other duties as assigned."

If you are in EMS long enough, it is probably only a matter of time before you find yourself explaining #2 as well.

Now in EMS, there is no formal training for it. I can tell you it is rather tricky. Grading new people on their ability I thought was awesome. But if you are going to do that you need to practice it.

So if these unpleasant tasks are something EMS providers have to do, why are they never taught?

Should it be part of initial education?

As part of independant field clearance?

A part of pre-employment screening?

 

[Hunter]

Nancy caroline book covers it a bit, but nothing more than general guidelines. Like; use terminal vocabulary, don't try and hint at it make sure it's clear and direct without being cruel. Allow a family member to react. They briefly cover the 5 stages of grieving.

 

[Veneficus]

Most of the textbooks have a paragraph or two in them on the topic.

But I can tell you that definately doesn't begin to cover it.

But you did not answer my question.

 

[Hunter]

Most of the textbooks have a paragraph or two in them on the topic.

But I can tell you that definately doesn't begin to cover it.

But you did not answer my question.

Because there's a lot of things we learn as, ojt eben though it should be taught initially.

Considering that it's not a common thing the only place to require it would be under initial education.

 

[VFlutter]

I think it should be included in the paramedic curriculum and then developed on the job. I do not think it should be part of a pre-employment exam because no matter how much you role play it does not adequately prepare you like actual experience. I think #1 is what paramedics will encounter the most but I am not sure situation #2 should be the responsibility of the medic. I am trying to think of situations in which a medic would have to tell the family that a patient is terminal. Most likely they a) already know or b) have been told and are denying it. For those situations I think there are better trained and more appropriate people to approach them (Doctor, nurse, chaplain).

 

[shfd739]

More coverage during school/training then continuing ed yearly from employer/agency.

 

[Veneficus]

I think it should be included in the paramedic curriculum and then developed on the job. I do not think it should be part of a pre-employment exam because no matter how much you role play it does not adequately prepare you like actual experience. I think #1 is what paramedics will encounter the most but I am not sure situation #2 should be the responsibility of the medic. I am trying to think of situations in which a medic would have to tell the family that a patient is terminal. Most likely they a) already know or b) have been told and are denying it. For those situations I think there are better trained and more appropriate people to approach them (Doctor, nurse, chaplain).

Disaster/MCA/Family on scene/failing resuscitation efforts during cardiac arrest.

 

[Christopher]

I had an interesting experience yesterday.

I was part of the first randomized testing group for a practical exam being developed for doctors as part of a residency selection process. (place must remain anonymous)

But it basically is a preemployment test.

While officially I cannot discuss specifics, (NDA) I want to talk about 2 things that I now think need to be added to the paramedic practical.

1. Telling a family member that their loved one is dead.

2. Telling a family member their loved one is terminal.

Now I know many do not think that is their job. But I can tell you it is only a matter of time before you have to do #1.

It falls under the part of your job description that reads: "all other duties as assigned."

If you are in EMS long enough, it is probably only a matter of time before you find yourself explaining #2 as well.

Now in EMS, there is no formal training for it. I can tell you it is rather tricky. Grading new people on their ability I thought was awesome. But if you are going to do that you need to practice it.

So if these unpleasant tasks are something EMS providers have to do, why are they never taught?

Should it be part of initial education?

As part of independant field clearance?

A part of pre-employment screening?

We definitely had it during our class and had scenarios which included situations not routinely tested by "NREMT-P" programs:

• Difficult refusals
• Termination of resuscitation on scene
• Watching a DNR patient die
• etc...

 

[Milla3P]

Disaster/MCA/Family on scene/failing resuscitation efforts during cardiac arrest.

This clarifies things.

My initial reaction was:

1) I'm sorry, there's nothing I can do. ( Usually escorted out by PD)

2) Becomes difficult. If its a chronic terminal illness the family should already be well aware and it is not my place. If the prognosis is questionable it certainly is not the place of a paramedic that does not have the education of a Doc to make these decisions.

Now, on the other hand, in an acute traumatic or cardiac event "It doesn't look good, but I'm going to do the best I can."

I've used both the lines from 1 & 2 in the past and will continue to do so.

The problem I have is with the chronically terminal patient.
The 2 separate and equally frustrating situations that I've personally encountered are that 1) family knows that elderly pt has terminal CA and that family and POA want to withhold that information from the pt while the pt continues to wonder why they get SOOOO sick and have to ED repeatedly while the POA requests that we keep our mouth shut regarding the Dx.
And 2) the pt's family are aware of a Dx and in complete denial of a terminal prognosis (Ex: stage 4 CA with multiple Mets) but are in complete denial and want an ICU to ICU transport for a second opinion from a second specialist that will report the same Dx.

These concerns are more about unrealistic POAs, sadly.

HOWEVER; these issues are harder to overcome when the general public as a whole still think that we throw the pt in the back, both get in the front seats and drive like hell.

 

[Veneficus]

We definitely had it during our class and had scenarios which included situations not routinely tested by "NREMT-P" programs:

• Difficult refusals
• Termination of resuscitation on scene
• Watching a DNR patient die
• etc...

You were very lucky then. This is the most I have ever heard of an EMS agency doing for this topic.

 

[medicdan]

Vene, what do you think of PALS' "Dealing with Pediatric Death" module? It's a video and companion discussion which is supposed to stimulate discussion about how to deliver news and the emotion charged in these situations?

 

[Veneficus]

Vene, what do you think of PALS' "Dealing with Pediatric Death" module? It's a video and companion discussion which is supposed to stimulate discussion about how to deliver news and the emotion charged in these situations?

many years ago it was part of the course, not an extra module. They simply gave a list of things to do and then showed a short videoclip on how to do it.

Unfortunately in order to keep the clip short, it turned up being exactly how not to do it.

It has improved, but still leaves a lot to be desired.

As part of my schooling I had to do a mandatory semester and clinical time in paliative care. Both adult and pediatric. Obviously that is not possible in the time of paramedic class, but I think it should be a skill check off that you were present for at least a few of them, even as just an observer.

When I was in my paramedic clinicals, one of the ED docs actually decided it should be a required skill for medics and with no training at all, he sent me into a conference room to deliver the news of a death. I learned a lot from that experience, but it didn't go as well as it probably should have.

Like anything else, the more you do it, the better at it you get.

 

[lawndartcatcher]

A lot of physicians use the SPIKES protocol, even for non-cancer discussions. Having a step-by-step process for the provider can make it easier from a procedural standpoint (prepping the provider to deliver the bad news, giving them a methodology and suggested responses, etc.). However, since everyone responds differently it's never going to be truly "easy" to do this. We've all had the hospice patient whose family didn't really get what "terminal" (or for that matter "hospice") meant and dialed 911 with the DNR still hanging on the patient's headboard.

Some of this should probably be covered by SOP as well; imagine a scene where four different providers are telling the patient's family four different things. Our service typically has the senior provider interact with the family at that level and we've got a fairly good list of truthful-yet-noncommital responses ("Your husband's heart has stopped beating so we're performing CPR" or "We're doing everything we can for your aunt - she's stopped breathing so we've inserted this tube to protect their airway") but in all honesty we usually let the ER physician deliver that news.

I agree that this would be a beneficial module in both EMT and Medic school - perhaps as part of a larger lesson called "the patient's family are human being, too, so stop shouting at them and treat them like you'd like your family treated".

 

[Michael]

I've found that we somewhat frequently do have to tell family members that their loved one is dead. When we got termination of resuscitation protocols, we did talk about this a bit, and did a bit of training.

One big thing that has caught on is informing the family members prior to finally stopping. This gives them the opportunity to say goodbye. The reaction from family members has been very positive.

 

[FLdoc2011]

If I'm involved with a code in the hospital I try and involve the family as much as they wish. Especially in instances where the pt is near terminally ill and undergoing futile treatments while the family has not fully grasped the extent of their illness, allowing them in usually provides needed closure and usually frees them to make a decision such as termination of efforts.

 

[VFlutter]

If I'm involved with a code in the hospital I try and involve the family as much as they wish. Especially in instances where the pt is near terminally ill and undergoing futile treatments while the family has not fully grasped the extent of their illness, allowing them in usually provides needed closure and usually frees them to make a decision such as termination of efforts.

Even the most adamant families quickly change their minds then they actually see what we do during codes. "They wouldn't want this" or "This is torture" are common feelings.