Ethical discussion to follow...

[VentMedic]

Ya...forget getting unpluged from the vent...I'll take 3ml of insulin any day instead.

There is a difference between removing from life support, which includes blood pressure supporting drips and ventilator, and bringing on death by other chemical means. Sedation and/or pain medication are used to make a patient comfortable but also careful guidelines are observed not to cross that fine line of "over medicating" to where one's actions could be questioned later. This also should be a comfort to the healthcare provider who must care for this patient but is not comfortable with "end of life" decisions. However, part of being a healthcare professional is being able to get your own personal feelings and beliefs under control to do what is legally and medically necessary to respect the wishes of the patients and families.

[lifesaver4u]

I have been watching this topic with much interest and I see both sides of the coin here. As a health care provider we are obligated to follow the wishes of this patient, it is her right to decline any advanced life saving measures she desires. But on the other side of this coin you could argue that maybe she wasn't compentent enough to make that decision. Maybe her understanding was impaired we do not know the extents of all her injuries the article was really not too informative on that aspect. What if her eye movement wasn't really in response to the questions she was being asked? I think maybe an ethics committee should have been called before she was taken off the vent. I would really have to have a lot more information about her condition, spinal injuries broken necks can be tricky in the best of worlds. Maybe more information is needed, its is easy for us to jump on the band wagon and say yeah she has the right to die but what if it wasn't really her wishes? Then we have committed the crime of murder.

[Arizonaffcep]

There is a difference between removing from life support, which includes blood pressure supporting drips and ventilator, and bringing on death by other chemical means. Sedation and/or pain medication are used to make a patient comfortable but also careful guidelines are observed not to cross that fine line of "over medicating" to where one's actions could be questioned later. This also should be a comfort to the healthcare provider who must care for this patient but is not comfortable with "end of life" decisions. However, part of being a healthcare professional is being able to get your own personal feelings and beliefs under control to do what is legally and medically necessary to respect the wishes of the patients and families.

I was actually speaking on my preference if I was in her shoes. Suffocation is not my preference on ways to go...

[ERDoc]

I think we are missing a few facts from a brief Yahoo article. This probably wasn't one of those come into the ER, CT shows you are paralyzed for life, let's pull the plug situations. I can almost guarantee that this case involved the hospital ethics committee. These are made up of MD/DOs, JDs, bioethitists(sp??) and anyone else that may be interested. There were probably several exams to decide if this woman was competent. There were probably several meetings of the ethics committee with some of these involving going over legal cases to look for precedence. I can guarantee you that this was a thought out and researched decision.

My feeling is that you cannot force treatment on someone who does not want it (as long as they have the capacity). She said no vent and to do that against her will is assault/battery.

[Just Plain Ruff]

I think we are missing a few facts from a brief Yahoo article. This probably wasn't one of those come into the ER, CT shows you are paralyzed for life, let's pull the plug situations. I can almost guarantee that this case involved the hospital ethics committee. These are made up of MD/DOs, JDs, bioethitists(sp??) and anyone else that may be interested. There were probably several exams to decide if this woman was competent. There were probably several meetings of the ethics committee with some of these involving going over legal cases to look for precedence. I can guarantee you that this was a thought out and researched decision.

My feeling is that you cannot force treatment on someone who does not want it (as long as they have the capacity). She said no vent and to do that against her will is assault/battery.

Thank goodness that most of us will never be put in this particular situation. We as EMS providers should never and I repeat never be required to turn off the vent.

[VentMedic]

Thank goodness that most of us will never be put in this particular situation. We as EMS providers should never and I repeat never be required to turn off the vent.

Are you against ending life support?

We have terminated several ventilators in the ED although not by EMS. Sometimes it is when a patient is alert and their DPOA has shown up with the paperwork for a DNR. If the patient is in agreement and expresses a wish for end of life support, we will honor it. However, more often than not, if a patient is intubated in the field before the patient's wishes are known, they may linger for days until the family, physicians and/or ethics committees can come up with a plan.

I have never had a problem pulling the tube and shutting off the ventilator for termination of life support. While some cases are sadder than others especially when it comes to infant and children but there is still a peace in knowing the alternative would be alot worse if the suffering or hope was allowed to continued.

[Just Plain Ruff]

Are you against ending life support?

We have terminated several ventilators in the ED although not by EMS. Sometimes it is when a patient is alert and their DPOA has shown up with the paperwork for a DNR. If the patient is in agreement and expresses a wish for end of life support, we will honor it. However, more often than not, if a patient is intubated in the field before the patient's wishes are known, they may linger for days until the family, physicians and/or ethics committees can come up with a plan.

I have never had a problem pulling the tube and shutting off the ventilator for termination of life support. While some cases are sadder than others especially when it comes to infant and children but there is still a peace in knowing the alternative would be alot worse if the suffering or hope was allowed to continued.

Nope and far from it Vent.

I am against putting me in the position of ending life support. The only time I should be required to end life support is when I've worked a code and we've gotten orders to cease efforts.

What I am against, and very strongly against is getting a call to a house and having someone tell me that I need to turn off the vent. Has it happened to me, nope not yet. Will it happen, more than likely in the foreseeable future but I DO NOT think it is my responsibility to turn the vent off. This should not be done by EMS. That is what I am against.

I was fully supportive of my grandfather being kept off life support and letting him go peacefully in a hospice situation.

I think you took my comments out of context. I hope I clarified the fact.

Have I turned off someone's vent in the ER, YEP I have. But to go out to someones house to do so is not appropriate for EMS to do.

[VentMedic]

What I am against, and very strongly against is getting a call to a house and having someone tell me that I need to turn off the vent. Has it happened to me, nope not yet. Will it happen, more than likely in the foreseeable future but I DO NOT think it is my responsibility to turn the vent off. This should not be done by EMS. That is what I am against.

Who is telling you to turn off the ventilator?

If someone did tell me to turn off a home ventilator, I would. And then they would have to put up with me bagging them to the hospital instead of being on the settings they have grown accustomed to.

I have had patients tell me quite often they want to die or "shoot me now" or "put me to sleep". We have also had family members attempt to turn off ventilators in the ICU which is why many of the hospital machines have a coded control panel. If a family member wanted their loved on dead in a home situation, there are plenty of ways to achieve that including turning off the ventilator. However, the ventilator will testify in court with its stored data.

Once life support is initiated, unless the patient is dead (yes they can be found dead with the ventilator still doing its job contrary to the belief of some), proper paperwork, signatures and orders must be obtained through a specific process for termination of life support to take place. For some, the process is moved quickly with a valid DNR and one or two doctors in agreement.

[Just Plain Ruff]

Who is telling you to turn off the ventilator?

If someone did tell me to turn off a home ventilator, I would. And then they would have to put up with me bagging them to the hospital instead of being on the settings they have grown accustomed to.

I have had patients tell me quite often they want to die or "shoot me now" or "put me to sleep". We have also had family members attempt to turn off ventilators in the ICU which is why many of the hospital machines have a coded control panel. If a family member wanted their loved on dead in a home situation, there are plenty of ways to achieve that including turning off the ventilator. However, the ventilator will testify in court with its stored data.

Once life support is initiated, unless the patient is dead (yes they can be found dead with the ventilator still doing its job contrary to the belief of some), proper paperwork, signatures and orders must be obtained through a specific process for termination of life support to take place. For some, the process is moved quickly with a valid DNR and one or two doctors in agreement.

I have not been put in this situation before so I don't know who would tell me to turn off the vent but let's just say it's the patients physician. This should only happen in a hospital situation but it wouldn't surprise me if it's happened already.

[VentMedic]

I have not been put in this situation before so I don't know who would tell me to turn off the vent but let's just say it's the patients physician. This should only happen in a hospital situation but it wouldn't surprise me if it's happened already.

I seriously doubt if they would ask you to turn off the ventilator and all you would have to do is say you know nothing about the ventilator and it is not the reason you were called or not part of your job description. You could also just say you are not comfortable doing that. About the only situation I could think up where this might happen and ONLY if the physician is present would be for a patient that has agonal respirations on the vent, is in hospital and is near death. Even at that it would be the physician that would assume the responsibility of shutting off the ventilator

You don't have to do everything a physician tells you if you are uncomfortable or it is harmful to the patient. If the physician who is present told you to push a medication at a dose which you know would be harmful and he/she still insisted, would you? Or would you again ask if he is sure that is the med and then hand the syringe to him? Nobody can make you kill a patient unless you are a willing participant or just have no clue about the situation situation.

I also will not just go into an ICU/ED and terminate life support at random just because a doctor ordered it unless it is a known patient with the proper orders and paperwork. As health care professionals we do have the right to do the right action to the right patient and ask for the right procedure to be followed at the right time if it involves our hands on the patient or technology. And remember, the doctor won't take the fall for your ignorance in a situation. That has been learned the hard way many times by many different health care professionals.

Edited March 14, 2010 by VentMedic