Scenario: Can you actually treat this patient?

[Akulahawk]

Clare, unfortunately for the US, we have a very litigious society. It's more legally defensible to provide care to someone that (quite literally) refused your assistance a few seconds ago than to withhold care absent some legally binding paperwork or a directive by a DPAHC (confirmed in writing). In short, if I'm perceived as withholding care, then I get into bigger trouble than if I don't.

 

[Clare]

Clare, unfortunately for the US, we have a very litigious society. It's more legally defensible to provide care to someone that (quite literally) refused your assistance a few seconds ago than to withhold care absent some legally binding paperwork or a directive by a DPAHC (confirmed in writing). In short, if I'm perceived as withholding care, then I get into bigger trouble than if I don't.

But again, if a competent patient has said to you with words that came out of their own mouth that they do not want resuscitation in the event of cardiac arrest then I do not understand how that cannot be considered an advance directive?

What does your code or charter or document of patient rights say about this?

 

[PotatoMedic]

Sadly if it is not in writing then it is the paramedics word verses families word. And the jury will always side with the family. Yes the patient wished one thing but family may not agree or they will see an easy way to make money.

 

[Akulahawk]

Worse still, even if it is in writing in the form of a witnessed refusal, families can still sue, cause some bad PR, and it's often cheaper to pay off the family and/or terminate the employment of a reasonably replaceable EMS worker than it is to defend against the lawsuit... even if the lawsuit is bogus. If you provide care under implied consent, regardless if the patient survives, lawsuits typically die early on because of implied consent and there's always the "PR" aspect where you "did everything." If the patient does survive and sues, juries aren't likely to say "yep, you should have died, they should have ignored their training and let you die, and therefore you wouldn't have been able to sue on your own behalf..."

It's very much a real pain in the backside. Don't get me wrong, I'm all for patient autonomy. If you choose to refuse care and it's witnessed, you should be allowed to keel over in front of me without me getting into trouble by walking away. Absent a DNR or POLST order... my hands are tied.

 

[Handsome Robb]

Clare, laws here vary so much state to state, county to county and city to city it makes for a very difficult discussion on things with a legal aspect.

I'm all for patient autonomy and personally in this situation would call a Doc and have them speak with the patient on the issue on a recorded line and if they insist on nothing being done then have them say that on the recorded line. After signing the AMA with a witness signature as well if they crumped in front of me I would start hands only CPR and immediately call the same facility back and request the same physician for termination orders. Depending on the doc I may or may not get them.

If they were able I would also try to get the PT's PCP on he phone and initiate proceedings for a DNR/POLST/MOLST. With our new POLST system in my state it's very plausible that I could have a POLST faxed or emailed to myself and the patient with the required signatures which would allow me to cease/not begin efforts if they did in fact arrest in front of me. An example of variances between states is some areas will honor DNRs on a Rx pad with a Physician's signature and license number or an Advanced Directive with the same information whereas where I'm at unless it's a transfer from hospital to nursing home I cannot accept the above noted versions and have to have a state issued DNR or POLST form signed by a physician. I cannot honor an Advanced Directive without consulting with online medical control, unfortunately.

In my opinion it's a broken system however because the culture in the U.S. is so litigious we truly do have to provide care, especially in a situation like this, in a fashion which covers our own ***. It sucks but it's the system we're stuck with for now.

As I said before I fully support patients being able to make informed decisions about their healthcare however I would have to jump through some flaming hoops to do so, which I'm fully capable and willing to do however some and Id argue that many providers, unfortunately, are not willing and have had CYA and "you will lose your certification and be sued drilled so far into their heads by our model of education that it is just downright easier to follow your written protocols in a situation like this and to let the hospital sort out the legal aspect of it. It's not right but it's a fact of life as an EMS Provider in the U.S.

Another big reason I personally think our hands are so tied in situations like this are due to our severe lack of education in legal issues applying to EMS as well as end of life decision making/care as well as a general lack of education. We aren't trusted to make big decisions like required in this situation without calling for help because we're still viewed as a vocational field filled with technicians rather than a profession filled with well educated clinicians.

 

[Brandon O]

Just to play devil's advocate, there is probably some value to formalizing the process of advanced directives. How seriously do we want to take every statement someone makes about their future care?

Even with properly-prepared directives it's not uncommon for patients to change their mind when the time actually comes. That's undoubtedly even more true for all the passing remarks about "Nah, I don't want none of that."

The idea of implied consent from patients who can't say otherwise is that really, most WOULD want care when in extremis, even if they thought differently when their situation was more theoretical. People don't want to die. This is true for the majority of patients, and overriding that default should be a decision made thoughtfully and carefully.

Ahead of time. In a doctor's office.

 

[Chewy20]

Say you do not work it, and then the family turns around and sues you. That is a CRAPPY thing to fight in court and I think we all know the outcome, plus your face will probably be on the news. The way things are nowadays I would much much rather deal with a pissed off alive dude that we got ROSC on, then a pissed off family with a dead relative saying they did not even try to work it. Whether he said it or not, the family will usually always win in cases like this unfortunately.

 

[joshrunkle35]

Start CPR. Contact online medical control. Explain situation. Let the doctor make the decision. Document. The end.

 

[ERDoc]

As the person who would be answering the medical control call, I would tell you to work it. You are not dealing with "the same condition prior to the cardiac arrest." The cardiac arrest is a new condition. Without anything in writting, you are on the hook. As Brandon O said, advance directives should be done ahead of time, in the appropriate setting where proper thought and discussion can be had, not when the pt is in extremis. Worse case scenario, you work it and the pt dies. Best case, you work it, the pt lives.

 

[Clare]

In New Zealand, patient rights are covered by the Code of Health and Disability Services Consumers' Rights and this covers all healthcare patients and personnel including ambulance personnel. It became law in 1996.

Right 7,5 states every consumer may use an advance directive and advance directive is defined in the Code as meaning "a written or oral directive - (a) By which a consumer makes a choice about a possible future health care procedure; and (b) That is intended to be effective only when he or she is not competent".

What is the equivalent of the HDC code in the United States? Surely it must contain similar provisions and these can justify honouring a competent patient's advanced directive (even if the family jump up and down about it - noting the family has no legal say in the matter unless they have an EPOA)?

 

[Brandon O]

Advance directive policies and laws are all state by state.

 

[DrParasite]

The condition the person refused care for is the STEMI. The cardiac arrest, while a result of the STEMI, is a different condition. The patient was conscious when they refused; now their condition has changed, and it's no longer the condition same condition.

I could much easier defend working a cardiac arrest than not working one. Even if an AMA refusal was signed for the stemi 10 minute ago.

 

[Handsome Robb]

@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.

 

[RedAirplane]

Suicidal people jump off buildings but may have second thoughts while accelerating through 9.8 m/s/s toward a poor unsuspecting Buick...

 

[Ewok Jerky]

@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."

The idea is you sit down and talk with the patient for 30-40 minutes explaining various situations, treatments, procedures, and outcomes. You do this is in a calm controlled environment where the patient can think and ask questions. Then they can go home and talk with family and come back with more questions before signing. That way, when they are in extremis, the conversation was had (syntax?) with proper thought and consideration.

Obviously you can't do this in the pre hospital setting, but done with the PCP makes the job of the ED and ICU much easier.

 

[Clare]

Obviously you can't do this in the pre-hospital setting, but done with the PCP makes the job of the ED and ICU much easier.

Rubbish. Why should a patient not be able to make an advanced directive to ambulance personnel, or for that matter, any other healthcare professional? The thing we must keep in mind is that it is the choice of the patient to do so and we should respect their wishes, provided they are competent to make decisions and articulate them.

 

[Ewok Jerky]

Because when someone is about to crash is not a good time to discuss sedation, intubation, ventilators, central lines, Foley caths, PICCs, LVADs, ICDs, dialysis, etc. When **** hits the fan on a call there is no time for discussion.

Look I'm all for patient autonomy, that is why these conversations should happen BEFORE we pick them up in the ambulance. Maybe you kiwis are more civil than we are in 'Merica, but even WITH an advanced directive if the family wants we worked we work it more often than not. Am I happy about that? No. But I would rather give the LIVING family peace knowing we tried. Plus, the dead patient can't sue you but the living family can.

 

[Carlos Danger]

Rubbish. Why should a patient not be able to make an advanced directive to ambulance personnel, or for that matter, any other healthcare professional? The thing we must keep in mind is that it is the choice of the patient to do so and we should respect their wishes, provided they are competent to make decisions and articulate them.

For several reasons, but primarily because, as Ewok pointed out, the decision to refuse life-saving intervention should be made only after lengthy discussion and careful consideration of the clinical situation and all of the possibilities. The patient needs to truly understand what they are asking for. Is a paramedic really the right person to educate the patient on and answer specific questions about all of the complex possibilities that could occur well after the EMS encounter? And is the patient's living room when they are having active chest pain or difficulty breathing really the time and place to do it?

The other major reason is legal. In America, the default assumption from a legal standpoint is that patients always want life-saving care, and are legally entitled to it. Of course patients have a right to refuse care, but in order to do so they have to go through a brief but important process with their physician so that everyone can be sure that they really understand what they are asking for, and that it is objectively documented in a way that is unambiguous and leaves no doubt in anyone's mind that the patient made the decision on their own, after considering all relevant information. It's not a perfect process, but the thinking is that it is better to err on the side of providing care to someone who may not want it than it is to not provide care to someone who really does.

It's not that patients have any less right to self-determination in the field, it's that such an important decision with such major implications (for not only the patient but their clinicians) has to be made in such as way that protects not only the patient's wishes, but also the legal rights of the clinicians involved.

 

[Clare]

Maybe you kiwis are more civil than we are in 'Merica, but even WITH an advanced directive if the family wants we worked we work it more often than not.

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.

For several reasons, but primarily because, as Ewok pointed out, the decision to refuse life-saving intervention should be made only after lengthy discussion and careful consideration of the clinical situation and all of the possibilities. The patient needs to truly understand what they are asking for. Is a paramedic really the right person to educate the patient on and answer specific questions about all of the complex possibilities that could occur well after the EMS encounter? And is the patient's living room when they are having active chest pain or difficulty breathing really the time and place to do it?

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.

The other major reason is legal. In America, the default assumption from a legal standpoint is that patients always want life-saving care, and are legally entitled to it. Of course patients have a right to refuse care, but in order to do so they have to go through a brief but important process with their physician so that everyone can be sure that they really understand what they are asking for, and that it is objectively documented in a way that is unambiguous and leaves no doubt in anyone's mind that the patient made the decision on their own, after considering all relevant information. It's not a perfect process, but the thinking is that it is better to err on the side of providing care to someone who may not want it than it is to not provide care to someone who really does.

It's not that patients have any less right to self-determination in the field, it's that such an important decision with such major implications (for not only the patient but their clinicians) has to be made in such as way that protects not only the patient's wishes, but also the legal rights of the clinicians involved.

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).

 

[NomadicMedic]

I guess you're lucky you don't live in the states.