EMS Should Be Involved With End Of Life Decisions


It’s a nightmare scenario played out all too often.  EMS is dispatched to a cardiac arrest.  The crew is greeted at the door by an upset family member who says that the patient has a DNR, and then produces paperwork that is not a DNR.  Perhaps it’s an advanced directive, living will, prescription with “DNR” written on it signed by their physician,  a physician’s order sheet that requests resuscitation not be initiated, or the correct form that is incorrectly filled out.  In any of these situations, the patient’s family called 911 expecting that CPR would not be performed when help arrived.

An equally difficult scenario is the near-arrest DNR patient with the proper paperwork, but does not take affect until after they have lost a pulse.   Each option brings career-threatening legal ramifications for us, threatens the dignity of dying patients, and affects the grieving process for their family.  Decisions must be made within seconds about what to do, and we only get one chance to get it right.

Each state’s laws are different, but in the three that I’ve worked in there is a state DNR form specific to EMS, which is the only form that could legally be honored.   The problem is that I have rarely seen one.  Patients who have the proper paperwork are the exception rather than the rule. Each doctor’s office supposedly has these forms, but for some reason they don’t make it to the patient.  When called to doctor’s offices, staff members are usually surprised to learn that we cannot honor the paperwork they produce, and say they have never heard of the one form that we can.  Everyone loses when a resuscitation is attempted on a DNR patient – the patient who wished to die without it, their family members who must watch, and EMS crews and hospital resources who are directed away from other emergencies.  If the patient is resuscitated, then family members must deal with decisions about when to withdraw life support.

By the time we get involved it’s usually too late, and it doesn’t need to be that way.  This is an area where EMS can be proactive.

On EMS Educast Episode 153, guest Bill Raynovich discussed some of these issues.  In one case a patient expressed her wish not to be resuscitated during a non-emergency transfer, but did not have a DNR, and later went into V-fib in front of the paramedic.  Ethics is one of many areas quickly glossed over at all levels of EMS education, and the solution starts with giving students better tools to make ethical decisions before they are placed in these situations.

Next, we can have conversations with people who do not want life-sustaining treatment before the 911 call happens.  When a patient discusses a DNR with their physician, find a way to get their information forwarded to their EMS service.  A community paramedic could visit them and explain the state DNR paperwork, and describe what EMS can and cannot do for them under state law.  A community paramedic could follow up with them a few weeks later to make sure their wishes are honored.

Finally, advocate to change palliative care laws.  Why can an advanced directive be honored in the hospital but not by EMS?  This is a great area to get together with hospice, nursing, and physician groups, because none of us want want to perform painful and expensive procedures on people who do not want their life to be sustained.  Why must families go through all the effort to compile end-of-life legal doccuments that can only be honored in the hospital?  Why can’t EMS honor the same legal doccuments as other healthcare providers?

Our interactions with a dying patient and their family is a chance for EMS to shine.  We need to make the most of them for everyone.

Comments

  1. Nereida Savoy, MSN, ARNP says:

    This is all too true, and so tragic. The health care workers usually feel terrible while reluctantly doing what they are obliged by law to do. EMS is a part of the team, and should be an active participant in recognizing when resuscitation is futile and even harmful.

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