Was I Wrong?

[HERBIE1]

I don't disagree that the patient has the right to do whatever they want, my point of contention is whether or not we should be helping them by providing transport for these people. We may not have the power to stop them, but is it right for us to be complicit in their harmful decisions?

I may try to find out more about my service's policy, however the way things are I'm a bit afraid of possible recourse for probing too deeply into this matter.

As was noted by others here, your job in that situation is to simply transport that patient home. I assume your service has a contract with the hospital, which stipulates they are the company who transports nonambulatory patients back home. I would assume it also includes IFT's as well. Your loyalty is to your company. There is no medical reason NOT to leave that patient, but certainly the social services issues need to be addressed as best you can, and as much as the patient is willing to agree to.

Tough situation, dude.

[Bieber]

So, the overwhelming sense I'm getting here is that I should have just shut up and done it without protest. Which, yeah, you are all right--I didn't do myself any favors by speaking out. And maybe the only way to get anywhere in this business is to just shut up and go with the flow, especially being new to it; and maybe I am very fortunate to still have a job after doing what I did. So for the sake of my career, I will accept that I made the wrong choice there.

But the one question nobody has answered is whether or not it was right for us to have left that guy there. I get it, my job is to do what my service tells me to do and any deviation is going to lead to me ending up on more people's shit lists. And I get that if I don't pick my battles more wisely, if I don't learn to shut up and do what I'm told, I'm going to be blacklisted. But ethically, is this right? Is it really okay for us to help someone make harmful decisions? I'm not talking about letting someone refuse service, I'm talking about actually helping them make bad decisions. Yeah, the guy had a home health aid, but no one else that came and could be with him or take care of him. Should we be complicit in people's bad decisions? I got into this business to help people, and it's a pretty shitty feeling to know that in order to preserve my job and my standing in my service that I have to shut up and just "go with it" when we take someone who could have found another way home back to his apartment where we KNOW he will be in a bad situation, a way that didn't make us at least in part responsible for what happens to him after he gets there.

It's a shitty feeling to know that if that guy dies there in that apartment, I'll have helped him get there and left him there knowing he was helpless as I walked out the door.

[DwayneEMTP]

...So my question to you is this: was I wrong to protest teching that call on principle?

Yes, you were wrong to protest it on principle, but you were not wrong to question it thoroughly on principle.

...Should I have just shut up and take him home without raising my voice against it?

I don't believe so, no. I believe that speaking with the pt about your concerns and with the doc if you felt it was appropriate was the right thing to do. But then, if it was truly the well informed pts wish, you should have taken him home.

... As far as I know, we have no obligation to provide a taxi service for patients going home from the hospital, only to provide transport and treatment to patients going TO the hospital.

Yeah, you just don't know this yet. Somewhere in the paperwork was a paper signed by the doctor describing this pts medical need to be transported home by ambulance as opposed to private vehicle or taxi. The pts doc asked for it and your company was/will be paid for it.

...And yeah, I know that guy was going to find a way home one way or another, but I strongly feel that we should not be involved in helping someone to harming themselves.

So do you then feel that the pt would have been better served by you and the EMS community had be been made to take a Taxi home? Long waits, embarrassing needs, perhaps unpleasant smells? A stranger and non medical professional to help him into his home and tuck him into bed? You're right, the pt IS going home, do you feel that we have advocated for him by making that journey as painful and embarrassing as possible?

...The first and highest edict in medicine is primum non nocere, first do no harm. But I feel like by having had a hand in putting that man in his home and leaving him there helpless, we have caused harm.

Do no harm is certainly the halo that surrounds our little profession, though being a pt advocate certainly hovers up there right next to. Your patient wanted to go home. You were called to care for this pt. If you felt that there were things about his/her condition that they didn't understand before going home then I believe that you were obligated to make them aware. If you felt that they were altered and not able to advocate for themselves, you were unquestionably obligated to do so. In this case you knew the pts wishes yet wished to thwart them as they made you uncomfortable, and that is the point that I believe you went off into the ditch. See?

...But the one question nobody has answered is whether or not it was right for us to have left that guy there.

Yes, if the pt was mentating appropriately, then following his wishes was the right thing to do.

...I get it, my job is to do what my service tells me to do and any deviation is going to lead to me ending up on more people's shit lists. And I get that if I don't pick my battles more wisely, if I don't learn to shut up and do what I'm told, I'm going to be blacklisted. But ethically, is this right?

No, it's not. You are not ultimately to do what you're told, you are ultimately to do exactly what you're doing now, which is learn to make the most competent, medically, morally and ethically sound decisions that you know how to the benefit of your pts regardless of your feelings. Will you end up in a shit storm because of it? Likely. When I was fired from my last job one of the last things the manager said is, "You do good medicine, it's just not paramedic medicine. We're not supposed to make people better, we're just supposed to save them if they're dying." I didn't know it then, but getting fired was exactly the right thing for me as I refuse to work in such a way.

I, as well as the others in this thread I'm guessing, find the morals and ethics of EMS to be at least as challenging as the medicine. I think that its possible that you read the replies from those that have been doing this longer than you and see that this is a simple decision for them, or me. It's not, it's only that we've had a few more days to think about it. I know how vitally important this topic is to those that have posted answers for you because I can see that their answers were not canned. They have thought about these issues from every angle, over many patients, had a bunch of broken hearts while developing the answers that you've been given. So please don't see them as flippant.

I was called to a lady during my FI at a new job a while back. She was in her late 80s, had been released from the hospital a few days before and her L lower leg was hugely swollen. She had been diagnosed with cellulitis which had now caused her entire lower leg to turn bright tomato red, hot as hell as well as cause her to present with general early stage sepsis. She was certainly going to die if she didn't choose to go to the hospital. We were not called by her but by a neighbor I believe...

She was mentating clearly, language quick and concise, much more intelligent and well educated than myself and many of my coworkers, and simply didn't want to go to the hospital because she knew that when she showed up that they would see that she was not becoming better, was unable to care for herself, would involve social services and she would be forced into a nursing home, her greatest horror. And she was prepared to die, in fact may have even welcomed it.

As a pt advocate, I wanted to refuse her, believe it or not. My instructions had been thorough up to and including, "Do you understand that it is my sincere belief that if you don't come with me today that we will be collecting your dead body from this chair within the next day or two? Not sicker, but dead.?" "If you have anyone that cares for you then you have no right to make such a foolish and selfish decision!" Lady, "I have no one that cares for me, no children, my family is all dead." Etc. Didn't softball her. But, as I was new at this service I chose to involve (after nearly an hour of effort) the police, my supervisors and social services to show them that I am in fact a team player. The police put her on a hold, I think, with social services signing off on it as her guardian, we took her to the hospital where she was treated and transfered to a nursing home who found her dead secondary to suicide a few weeks later. Oprah maybe would praise my efforts, but the bottom line is that this woman knew her own mind, she had a human right to choose to live and/or die at where she chose, yet me and a bunch of other yahoos decided to 'do the right thing' and make her die miserably. Major bruise to my paramedic spirit.

You worry that you helped this pt make a decision that would bring them harm, and that is simply not true. You helped, or your partner did at least, this person carry out the decisions that they had made for themselves. Two completely different things.

I love the fact that this is giving you heartache. I love the fact that you're pissed off that people don't seem to care about this patient. And I'm confident that if you are strong enough to have convictions and stand by them, a rarity in EMS, that you are going to be a fucking rock star medic.

Dwayne

...It's a shitty feeling to know that if that guy dies there in that apartment, I'll have helped him get there and left him there knowing he was helpless as I walked out the door.

I can promise you that it's an even shittier feeling knowing that you've taken someone in the last days of their lives and physically forced them to live out those days in a manner that they despise.

It occurs to me that we haven't, in all of this learned conversation, considered the bullshit factor here. The truth is that some pts want to stay in the hospital. They like it, and the care that they receive, there much better than they like home or a nursing facility. But the truth of the matter is that we simply can't afford to keep everyone there that would like to stay.

As I reread your post it sounds like it is possible that this pt was giving the answers he believed that he needed to give to be too sick to go home or to a nursing home but yet sick enough to stay in the hospital. I can't think of a single pt that I've had that TRULY wanted to go home that would admit to not being able to care for themselves. It's almost always the opposite. They are swearing that they can (as in the leg lady) when I know damned good and well that they can't.

Just a thought...

Dwayne

[uglyEMT]

After Dwayne's post I dont have much more to add except this.

You really did no harm, this was a AOx3 patient wishing to go home. If he was told, as it did sound like because of the HHA, he would need help and better suited to a nursing home but still wanted to go home then thats his wish.

It would be the same as a DNR call. It sucks but you have an obligation to honor the wishes of the patient and/or patient advocate.

I'll give you a real world example so you see where I am coming from. Called to a home for difficulty breathing, get there and here is a man in a hospital bed in the living room. We can see the extreme distress he was in and were just about to do our thing when the wife presents us with the DNR. Didnt verbally tell us but presented it to us. We had to take a step back and it broke our hearts as we had her sign out paper work and walk out. Apparently the young daughter called us without the wife's knowledge so thats why we were there. Did we want to say "outta my way, we can save him." Of course but we couldn't and didn't. I went out and punched the side of my rig afterwords but honored the patient's wishes.

Morals and ethics are a tough thing in our profession that sometimes we wrestle with. Its good to see you were speaking up and being a patient advocate, we need more of you in this profession. You will be a kick ass medic if you keep it up. Do I think your partner was an ass for making you feel like your job was on the line because of it, abso-freakin-lutely! But one thing you need to remember is after giving a patient all the information they can still refuse treatment, thus in this case transport home even with no mobility.

[BEorP]

It's a shitty feeling to know that if that guy dies there in that apartment, I'll have helped him get there and left him there knowing he was helpless as I walked out the door.

I understand your concern and it is refreshing to see that there are still people who are about the patients. That being said, autonomy is one of the major principles of medical ethics. If this patient goes home and dies in their bed and that's what they wanted then that is excellent. I commend you for at least questioning it while at the hospital to ensure he wasn't being discharged home unwillingly when he would be unable to manage, but once you found out he was competent and wanted to be left at home there is not much more for you to do.

A couple other quick points. On the quote above, with a phone in reach he is far from helpless. He knows our number. Maybe I missed it, but I don't recall seeing any mention of family or friends. For all we know, he is going to immediately be calling a family friend who will be coming by to assist him but he is just too proud to admit it to you.

And to end off with a quick personal anecdote... a couple years ago I was called for an elderly lady who had a syncopal episode while having an evening drink on her porch with a friend. There wasn't any obvious cause of it and of course it could have been anything from no big deal to her needing a pacemaker. She did not want to go to the hospital and was adamant about that. In the course of ensuring that she understood the situation, I explained to her that we couldn't say for sure whether it was a serious problem or not but that it could be and she could potentially die from it. Her reaction? She smiled and said, "Yes, that's fine. I'd be happy to go right here."

Would you have felt guilty leaving that patient there? I sure didn't.

I'll give you a real world example so you see where I am coming from. Called to a home for difficulty breathing, get there and here is a man in a hospital bed in the living room. We can see the extreme distress he was in and were just about to do our thing when the wife presents us with the DNR. Didnt verbally tell us but presented it to us. We had to take a step back and it broke our hearts as we had her sign out paper work and walk out. Apparently the young daughter called us without the wife's knowledge so thats why we were there. Did we want to say "outta my way, we can save him." Of course but we couldn't and didn't. I went out and punched the side of my rig afterwords but honored the patient's wishes.

Is this just something in your region/state that DNR means do not treat and you simply leave a patient who is still alive but in distress since they have a DNR?

[uglyEMT]

Is this just something in your region/state that DNR means do not treat and you simply leave a patient who is still alive but in distress since they have a DNR?

The protocol in my area states that if presented (and only when presented) with a DNR we must honor whatever it states on the order. In this patients case it said no interventions could be preformed. From what we did hear from the wife she called hospice to have the nurse come out and declare after he passed it was the daughter who called us. The family (except the daughter) had no intentions of calling us, this was what they wanted. Thankfully (for their wishes including the patients) they produced the DNR, if not we would have been doing what we had to.

We have seen them say everything but CPR, yes to BVM but no to resperator, ect, ect, ect. These orders are on an official document that we get a copy of to attach to our paperwork and have a physicians signature on them, along with a witness. So we follow it no matter what we see upon arrivial as long as it is produced to us, we cant just take someones word, we need to have the document in our hands.

Sorry I didnt make this clear in my last post, for that I appologize. I forget sometimes we are all over the place and what protocols I have differ from others.

[spenac]

First I did not read all comments as no time so if others already addressed this sorry.

You were wrong. A patient can tell you no to any procedure or even all procedures and just have you transport. You should have taken this patient it was your responsibility. You protect yourself by explaining the risks to the patient then documenting your explanation and the patients refusal to listen but that the patient was competent. The patient hired your service thus it could be said they hired you for a taxi ride and it was your job to comply with the patients wishes. I would have written you up if not terminated you for refusal to comply with your job description.

Be grateful that you are being given a second chance. Learn from it. Communicate with the patient then document the communications. A grown competent person can decide to take the risks, it is not your place to decide what is acceptable for them.

[Just Plain Ruff]

I read this with interest.

The patient or his insurance company will pay for the transport. It really matters not if you think you are taking the patient to their own demise.

You cannot help all the people all the time.

I think you should have teched the call.

Remember, this guy was able to get around on his own prior to the fall, what makes you think that he won't be able to again?

The best outcome of this situation is that the guy has this home health person who comes in daily. The home health nurse goes to her social services department, reports an incident or hotlines the guy, the state comes in, the state works with the social services agency to get him round the clock help and all is good.

WE as EMS providers can only do so much.

If you want to do more, then you make the call to the Elder neglect and abuse hotline or call the social services department of the hospital he was released from. You are really mandated by the state to do so at least you are in Missouri.

Once you make that call then this is out of your hands and you can go on to save the world in another productive way, one patient at a time.

[DwayneEMTP]

... The patient hired your service thus it could be said they hired you for a taxi ride and it was your job to comply with the patients wishes. I would have written you up if not terminated you for refusal to comply with your job description....Be grateful that you are being given a second chance...

And I'm just the opposite. You would have immediately, despite your short time in the profession, fallen on my radar as someone I could trust to put humans above money. The world is full of people that will do whatever they are told simply because they are afraid of being fired. It is much more rare to find someone that is willing to take a beating to advocate for another. I wouldn't soon forget that, and that attitude would keep you hired in the Dwayne the shithead ambulance company long after I'd fired more experienced but less caring medics.

When I first got my medic ticket I went to my wife several times, here and in Afg, asking her, "What should I do!?! If I do what's right I'll get fired, if I do what will keep me hired then I don't know how I consider myself a real medic!" And she always told me that there would be other jobs, but that I could never again pretend to be a good medic if I CHOSE to be a bad medic today. That I could never pretend that I hadn't decided how much my integrity was worth and found that price to be a few hundred dollars. I thank goodness that I've proven that it's worth more than that. And you know what? I've been fired, but have never been without a job....

You get jammed up for following your morals, let me know and I'll go to bat for you, or akflightmedic, or Dustdevil, or Lone Star and on and on... I had a good friend tell me when I got fired from my last job, a medic that I respect a lot, that he's never known a good medic that hasn't been fired. I believe I can now say the same thing more or less....Morals and ethics are often unpopular. But you didn't spend all of that time and money becoming a medic to enter a popularity contest, right?

You maybe should have made a different decision with this patient, but don't you dare question whether or not exploring your options, questioning authority or being heart broken because you were forced to help a pt do something that you felt was harmful. Those are all really, really good, strong, kind, professional, yet almost universally unpopular, things to do.

Dwayne

[mobey]

First I did not read all comments as no time so if others already addressed this sorry.

You were wrong. A patient can tell you no to any procedure or even all procedures and just have you transport. You should have taken this patient it was your responsibility. You protect yourself by explaining the risks to the patient then documenting your explanation and the patients refusal to listen but that the patient was competent. The patient hired your service thus it could be said they hired you for a taxi ride and it was your job to comply with the patients wishes. I would have written you up if not terminated you for refusal to comply with your job description.

Be grateful that you are being given a second chance. Learn from it. Communicate with the patient then document the communications. A grown competent person can decide to take the risks, it is not your place to decide what is acceptable for them.

Dude, you must be sick or tired, this post has no quality at all.

OP: Just because you get disaplined or fired for something, does not mean you were wrong.

I agree, you have alot to learn from this experience, and many more, but you were not flat out WRONG. You were faced with a moral dillema, and you stood your ground on what you thought was best for the patient. This was not a drug dose, there is not a right & wrong answer. The more dillemas you are faced with, the higher your tolerance will be, and the more you will grow as a professional. You have the pts needs at heart, that means you are in the right buisness. Sometimes the drive to keep people healthy overcomes our compassion to let people die on thier own terms. Ever had someone with chest pain refuse ASA/Nitro? I have.... it sucks! But they are ready to go, and we need to agnowledge thier feelings (NOT assist, might I add!).