EMS2712 Posted March 11, 2009 Posted March 11, 2009 On a run last night, our squad was dispatched to the residence of male heart patient, who was unable to get up. Upon arrival found patient lying on floor. Family advised that they were assisting patient back to bed, and he became weak, and was lowered to the floor. Patient is under Hospice care due to severe 25% cardiac output. Patient is lethargic, with vitals as follows. P 168, BP 104/68, R 20. A-patent, B-spontaneous and non-labored, C-normal, warm and dry. Monitor shows a narrow tachycardia, with no visible "P" waves. Patient's family refuses patient to be transported d/t the fact if the patient is transported they would lose their Hospice care. Family advised that they have been instructed that they must call Hospice to determine if they should call 911, and if they do and have him transported, they will lose Hospice care. What are your thoughts on this?
robert gift Posted March 11, 2009 Posted March 11, 2009 On a run last night, our squad was dispatched to the residence of male heart patient, who was unable to get up. Upon arrival found patient lying on floor. Family advised that they were assisting patient back to bed, and he became weak, and was lowered to the floor. Patient is under Hospice care due to severe 25% cardiac output. Patient is lethargic, with vitals as follows. P 168, BP 104/68, R 20. A-patent, B-spontaneous and non-labored, C-normal, warm and dry. Monitor shows a narrow tachycardia, with no visible "P" waves. Patient's family refuses patient to be transported d/t the fact if the patient is transported they would lose their Hospice care. Family advised that they have been instructed that they must call Hospice to determine if they should call 911, and if they do and have him transported, they will lose Hospice care. What are your thoughts on this?What is accomplished by transporting him to a medical facility? How will they get him home? Put him in bed and have them & him sign a refusal. Age? Weight? O2?
FireMedic65 Posted March 11, 2009 Posted March 11, 2009 What did the patient want? It's not up to the family, it is up to the patient. I would have treated the patient for the SVT. Consulted with medical command. Regardless of the patient's hospice, you were dispatched there. You can't just leave without treating the patient, unless there was a DNR stating as such. Make the patient comfortable, treat their symptoms.
spenac Posted March 11, 2009 Posted March 11, 2009 You must honor the patients wishes. Often Hospice patients and there familys call just needing assistance like lifting or they panic. Do not try and force unwanted measures on the patient. Whether you agree or not it is their choice and their right to die with some control. There is nothing we can do that will save them so do only what you are asked. I hate people thinking they can force themselves where they do not belong. If they ask for assistance such as suctioning, fluids, etc. Do it. If they ask to go to the hospital. Do it. If they ask you to check vitals and help lift them. Do it. If they say do nothing else. Then do nothing else.
RatPack Posted March 11, 2009 Posted March 11, 2009 On a run last night, our squad was dispatched to the residence of male heart patient, who was unable to get up. Upon arrival found patient lying on floor. Family advised that they were assisting patient back to bed, and he became weak, and was lowered to the floor. Patient is under Hospice care due to severe 25% cardiac output. Patient is lethargic, with vitals as follows. P 168, BP 104/68, R 20. A-patent, B-spontaneous and non-labored, C-normal, warm and dry. Monitor shows a narrow tachycardia, with no visible "P" waves. Patient's family refuses patient to be transported d/t the fact if the patient is transported they would lose their Hospice care. Family advised that they have been instructed that they must call Hospice to determine if they should call 911, and if they do and have him transported, they will lose Hospice care. What are your thoughts on this? Pt is lethargic. He goes. Just because he has a pre-existing medical issue and is a hospice pt. doesn't exclude him from treatment or the fact that some other entirely different issue has arisen. Like stated before. Did he want to go? I dont understand the hospice stance. He will lose hospice care. For what? Seeking medical treatment? Another angle, if he/they didn't want him to go why did they call? Just curious.
VentMedic Posted March 11, 2009 Posted March 11, 2009 (edited) On a run last night, our squad was dispatched to the residence of male heart patient, who was unable to get up. Upon arrival found patient lying on floor. Family advised that they were assisting patient back to bed, and he became weak, and was lowered to the floor. Patient is under Hospice care due to severe 25% cardiac output. Patient is lethargic, with vitals as follows. P 168, BP 104/68, R 20. A-patent, B-spontaneous and non-labored, C-normal, warm and dry. Monitor shows a narrow tachycardia, with no visible "P" waves. Patient's family refuses patient to be transported d/t the fact if the patient is transported they would lose their Hospice care. Family advised that they have been instructed that they must call Hospice to determine if they should call 911, and if they do and have him transported, they will lose Hospice care. What are your thoughts on this? Were you dispatched just as a lift assist? If so, who asked for further medical intervention? What were the famiy's expectation the care to be provided by you? If it was for a lift assist and the patient is in hospice, that should be honored. A DNR is applied when the patient codes. It doesn't mean "do not treat" prior to that. Hospice and Comfort care orders go beyond a DNR. Vitals are rarely if ever done on comfort care or hospice patients even in the hospital since many of their meds are maintenance and the others are titrated purely by comfort level...not BP or HR. Any form of treatment to prolong life has been discussed and decided against. We have had ambulances transporting to LTC facilities or home fail to understand these orders. Thus, they turn around and run L&S back to the hospital ED because they found the SpO2 to be 80% on 2 L NC and have placed the patient on a NRBM or will be bagging them. Orders usually consist of 2 - 4 L only with no SpO2 monitoring. The respiratory comfort is done by medications, not SpO2 checks since there is little way to adequately oxygenate the body with a failing heart without a lot of technology and drips. If they revoked his hospice status, he could become a full code which would mean intubation and what remains of his life will be full of technology,little privacy and pain since the comfort meds will take a back seat to stabilizing blood pressure. Once the initial resuscitation is done, the doctors and family will then have to go through the withdrawal of life support, probably for the second time, and attempt to make hospice arrangements again or just have the patient die on med-surg in a room with 1 to 3 other patients. If you are unsure what to do, contact hospice and your med control before aggressively resuscitating espeically if they have hospice papers or the equipment of hospice attached to the patient. Edited March 11, 2009 by VentMedic 1
FireMedic65 Posted March 11, 2009 Posted March 11, 2009 Were you dispatched just as a lift assist? If so, who asked for further medical intervention? What were the famiy's expectation the care to be provided by you? If it was for a lift assist and the patient is in hospice, that should be honored. A DNR is applied when the patient codes. It doesn't mean "do not treat" prior to that. Hospice and Comfort care orders go beyond a DNR. Vitals are rarely if ever done on comfort care or hospice patients even in the hospital since many of their meds are maintenance and the others are titrated purely by comfort level...not BP or HR. Any form of treatment to prolong life has been discussed and decided against. We have had ambulances transporting to LTC facilities or home fail to understand these orders. Thus, they turn around and run L&S back to the hospital ED because they found the SpO2 to be 80% on 2 L NC and have placed the patient on a NRBM or will be bagging them. Orders usually consist of 2 - 4 L only with no SpO2 monitoring. The respiratory comfort is done by medications, not SpO2 checks since there is little way to adequately oxygenate the body with a failing heart without a lot of technology and drips. If they revoked his hospice status, he could become a full code which would mean intubation and what remains of his life will be full of technology,little privacy and pain since the comfort meds will take a back seat to stabilizing blood pressure. Once the initial resuscitation is done, the doctors and family will then have to go through the withdrawal of life support, probably for the second time, and attempt to make hospice arrangements again or just have the patient die on med-surg in a room with 1 to 3 other patients. If you are unsure what to do, contact hospice and your med control before aggressively resuscitating espeically if they have hospice papers or the equipment of hospice attached to the patient. A DNR IS NOT just for when a patient codes. It can state anything the patient wants in regards to their treatment. A patient can have DNR that says they don't want oxygen more then 10li/min.
spenac Posted March 11, 2009 Posted March 11, 2009 Pt is lethargic. He goes. Just because he has a pre-existing medical issue and is a hospice pt. doesn't exclude him from treatment or the fact that some other entirely different issue has arisen. Like stated before. Did he want to go? I dont understand the hospice stance. He will lose hospice care. For what? Seeking medical treatment? Another angle, if he/they didn't want him to go why did they call? Just curious. Sounds like you need to spend some time with Hospice. I suggest you volunteer some time with them and get a better understanding. As to why did they call? Maybe they need lifting assist. Maybe they paniced. Not your place to disregard the wishes of the patient. Sometimes familys call because they need assistance as they do not know how to do something and the hospice nurse or volunteer is unavailable. Go be a help not a sorce of stress in an already trying time. 1
VentMedic Posted March 11, 2009 Posted March 11, 2009 (edited) A DNR IS NOT just for when a patient codes. It can state anything the patient wants in regards to their treatment. A patient can have DNR that says they don't want oxygen more then 10li/min. DNR stands for DO NOT RESUSCITATE. DNR orders can also have an accompanying DNI order but that may not mean you withhold oxygen. More than 10 L? Did they specify the device? For some devices, 10 L might only be 28% or even 24% Oxygen. And, some cheap prehospital CPAP devices can function at 10 L. That order would be vague and very open to medical/legal interpretation. Yes, a DNR order can get specific as to whether it is meds only with or without compressions when the patient goes into a life threatening condition where a code will be the very likely. But, again, it is meant for resuscitation. IF the condition can be treated and is seen as reversible, the DNR does not apply. Thus, it is not meant to be a DO NOT TREAT. We do set up high flow cannulas up to 40 L/m on even comfort care patients if that is part of their specific agreement especially on patients with some form of fibrosis. However, it is just part of comfort and no vitals, including SpO2 are monitored. It they still have a strong feeling of dyspnea, they will get IV meds and a morphine or fentanyl nebulizer. The point is, YOU should be familiar with the types of orders and documentation specific to your state and local area. YOU should understand the differences in the various orders and be careful when reading the orders. What YOU don't understand you should immediately contact the sources involved with the orders, hospice or the MD, and your med control. Do not assume. Edited March 11, 2009 by VentMedic
FireMedic65 Posted March 11, 2009 Posted March 11, 2009 DNR stands for DO NOT RESUSCITATE. DNR orders can also have an accompanying DNI order but that may not mean you withhold oxygen. More than 10 L? Did they specify the device? For some devices, 10 L might only be 28% or even 24% Oxygen. That order would be vague and very open to medical/legal interpretation. We do set up high flow cannulas up to 40 L/m on even comfort care patients if that is part of their specific agreement especially on patients with some form of fibrosis. However, it is just part of comfort and no vitals, including SpO2 are monitored. It they still have a strong feeling of dyspnea, they will get IV meds and a morphine or fentanyl nebulizer. The point is, YOU should be familiar with the types of orders and documentation specific to your state and local area. It's called an example. You should really read up on things before you go running your gums. A DNR can state anything the patient wants it to state. Yes, I have seen DNR's written to be very specific of what the patient wants. Mostly out of nursing homes. I always look them over and A LOT of the time, the patient wants CPR, intubation, ACLS measures, medications. They are very specific on what they want and do no want. Just because DNR stands for do not resuscitate, does not mean you have to wait for them to die to know what they want or do not want in case of ANY emergency.
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