Save the Medic, or Spare the Family?

[Farmer2DO]

I teach my paramedic students and new grads to make the decision about death clinically, and not even put on the monitor unless you are starting CPR.

As for the wishes of the family and patient, I've called dozens of times and explained that technically the paperwork isn't in order, but this elderly person's death was expected, and the family would like them to be allowed to die. Or, the paperwork is found after we've started. That one has happened many times. I've never had a problem and always been allowed to call it. Beating on a dead body because some remote physician is scared of liability is ridiculous.

(I have no problem with what you guys did; it sounds like you were just functioning in the system you work in.)

 

[Fish]

If we are putting a Monitor on it is because there is no obvious signs of death and the Pt. is Viable, but once we get a pronouncement then thats it. Unless the Pt. magically goes into a shockable rythm right infront of my eyes after being Asytole the whole time, or if he suddenly has a pulse.

That being said, my system is different than yours, and I do not believe we can judge you for following your policies. Even though they sound very strange. Those Beats every 15 seconds or so, are just as bad as Asytole and will have the same outcome.

 

[imadriver]

I think the medic thought about turning off the monitor. The only problem was the fact he just got released from the hospital. But couldn't tell you exactly what he was thinkin.

And from the reading I've been doing really in depth on our protocols it was a loop hole kind of thing.

Everything was fine until we called the death. As per our protocol, we should of called Med Con for the simple fact that he wasn't showing he was dead enough. We run pretty much flat line cardiac arrests all the time, but usually they are not showing any signs of death and even a little bit of life., other then the whole heart not beating thing.

But this whole call went into that "gray area" in our protocols. We weren't right, but we weren't wrong.

 

[AmeriMedic21]

We would most likely have ran it as a code to begin with. On because no lividity, no noticeable rigor, and pt is not cool to touch. I was always taught that they arent dead, until they are warm and dead. Our service would run this as a code. We would have applied Fast Patches and 12 lead after CPR has been initiated, and once we start, we rarely stop, unless ordered to. I have found myself in that ackward situation of showing up on a code blue, and the family informs us that they have a DNR. When we asked the family to produce the DNR and they couldnt, we started CPR. I was being cussed at, we had one of the LEOs call the hospital to validate a DNR, we ultimately stopped, but i mean we couldnt just take their word on it ya know?

 

[Farmer2DO]

but i mean we couldnt just take their word on it ya know?

Why can't you take their word on it? Doesn't family, and their wishes, and what the patient wanted, matter? Don't the family and the patient get a say? There are going to be times when we encounter patients that don't have a DNR in hand, but they should NOT be worked. There should be an avenue for providers to contact medical control and NOT resuscitate certain people. If family is cussing at you, then you are violating their family member's body. A system is badly broken if this happens and there is no way to get around it.

 

[tssemt2010]

how long had he been down before you guys decided to work it? if the down time was that long, forget about it, i agree, not a chance i wouldve worked this guy

 

[d0nk3yk0n9]

Why can't you take their word on it? Doesn't family, and their wishes, and what the patient wanted, matter? Don't the family and the patient get a say? There are going to be times when we encounter patients that don't have a DNR in hand, but they should NOT be worked. There should be an avenue for providers to contact medical control and NOT resuscitate certain people. If family is cussing at you, then you are violating their family member's body. A system is badly broken if this happens and there is no way to get around it.

Legally, I cannot accept anything except the NY State Prehospital DNR form as a valid DNR. Nothing else, not the family's verbally expressed wishes, power of attorney, living will, etc. is sufficient. Now, at the point that they say there's a DNR but can't produce it, I'm going to start CPR, since I'm required to do so, but I'm also going to contact medical control and try to get orders to terminate resuscitation.

 

[imadriver]

All of it happen rather quickly. I'd say 5-10 minutes really before we "started" cpr. We took it easy on him.

Also, our system is the same. They HAVE to have a DNR on a yellow piece of paper and fully filled out in order for it to be valid. Otherwise, we run them.

When I put everything together, as per our protocols, we should of ran this guy from the get go. However, we were TRYING to protect the families wishes. But that's when it fell into the gray area, and we, and the family, kinda got screwed into the whole thing...

The worse part was, once we got to the hospital, they called him within 5 minutes... They hardly even worked him.

 

[usalsfyre]

The worse part was, once we got to the hospital, they called him within 5 minutes... They hardly even worked him.

Can you blame them? He didn't want to be worked and was in an agonal rhythm. Not exactly conducive to ROSC.

I'm sorry, but this was cookbook medicine at it's finest.

 

[Farmer2DO]

Legally, I cannot accept anything except the NY State Prehospital DNR form as a valid DNR. Nothing else, not the family's verbally expressed wishes, power of attorney, living will, etc. is sufficient. Now, at the point that they say there's a DNR but can't produce it, I'm going to start CPR, since I'm required to do so, but I'm also going to contact medical control and try to get orders to terminate resuscitation.

Not true. I also work and practice in New York State. If there isn't paperwork, and the family doesn't want them worked, I am immediately on the phone with medical control. Doesn't matter if there is a DNR present or not. On a patient that shouldn't be worked, CPR isn't started until I have a medical control physician order it. And in 13 years as a paramedic, that's NEVER happened.

 

[imadriver]

Can you blame them? He didn't want to be worked and was in an agonal rhythm. Not exactly conducive to ROSC.

I'm sorry, but this was cookbook medicine at it's finest.

haha, That's what I'm sayin, The doc in the room was the same doc on the phone, and he just goes, "Yeah, I see what you mean. . . Alright, lets call him! Time of death?"

 

[Farmer2DO]

Legally, I cannot accept anything except the NY State Prehospital DNR form as a valid DNR. Nothing else

Also in NYS we have the MOLST, which is valid for prehospital use as a DNR order.

 

[d0nk3yk0n9]

Not true. I also work and practice in New York State. If there isn't paperwork, and the family doesn't want them worked, I am immediately on the phone with medical control. Doesn't matter if there is a DNR present or not. On a patient that shouldn't be worked, CPR isn't started until I have a medical control physician order it. And in 13 years as a paramedic, that's NEVER happened.

Okay, but you're a Critical Care Paramedic, while I'm still an EMT-B student, so you presumably have a lot more leeway in making that call than I do. So far, having never been in that situation, I'm just going off of what my textbooks, protocols, and instructors have told me. If my instructors are wrong, let me know, as I'm always looking to learn as much as possible, especially from experienced providers.

 

[STXmedic]

Okay, but you're a Critical Care Paramedic, while I'm still an EMT-B student, so you presumably have a lot more leeway in making that call than I do. So far, having never been in that situation, I'm just going off of what my textbooks, protocols, and instructors have told me. If my instructors are wrong, let me know, as I'm always looking to learn as much as possible, especially from experienced providers.

Don't expect your instructors to be the know all prophets of EMS. I've seen MANY piss-poor instructors that couldn't tell you a King from a Combi.

I'm with Farmer on this, and it's not something that's Critical Care paramedic specific. If you feel the patient stands little to no chance to be resuscitated (not just get a pulse back), and the family feels it's the patients wishes to be let alone, then there is no reason to not call up your med director and request a termination of efforts. (Not going to get into the "calling med director for everything" debate)

 

[d0nk3yk0n9]

Don't expect your instructors to be the know all prophets of EMS. I've seen MANY piss-poor instructors that couldn't tell you a King from a Combi.

I'm with Farmer on this, and it's not something that's Critical Care paramedic specific. If you feel the patient stands little to no chance to be resuscitated (not just get a pulse back), and the family feels it's the patients wishes to be let alone, then there is no reason to not call up your med director and request a termination of efforts. (Not going to get into the "calling med director for everything" debate)

Thanks for the clarification, and, like I said, I'd probably be calling medical control ASAP as well for orders to call it.

 

[Farmer2DO]

Yeah, if you arrive and find someone pulseless and the family is asking you not to work them, for whatever reason, you should be calling. We have an obligation to the patient and their family. We also have an obligation to the system not to over burden them with useless CPR cases, using beds, time, resources, personnel, an ambulance and thousands of dollars.

Short story from my experience:

80 some year old patient. Arrangements made to transfer him from home to the hospice center. End stage cancer with metastasis everywhere. Weighs like 95 lbs. Alert and oriented, acknowledges where he's going and why. Family advises that he's been given less than a month to live. Discharge paperwork from a local hospital confirms all this. Transfer set up by the hospice center with whom we do a ton of work. BLS crew goes; pt stands and pivots with assistance, sits, and arrests. Dead. The crew asks for the paperwork showing DNR; family says it's at the hospice at the other end and they don't have a copy. Crying, BEGGING to let him die. BLS crew doesn't know what to do. I'm close, so I go in and immediately get on the phone. Explain that this guy needs to die, and get approval not to work him. With no paperwork, it was important to get a physician involved.

Common sense goes a long way in these situations. If you tell the medical control physician you have good faith that the patient needs to die and the family wants it, they should back you.