To tube or not to tube

[NYCEMS9115]

In NYS, EMS needs to honor DNR, Living Wills, Power of Attorney, Heathcare Proxies, & MOLST. Enough is enough. No more confusion & ethical dilemnas...

[chbare]

In NYS, EMS needs to honor DNR, Living Wills, Power of Attorney, Heathcare Proxies, & MOLST. Enough is enough. No more confusion & ethical dilemnas...

There will always exist ethical dilemmas in this line of work. People may not always agree and different interpretations will always exist no matter how concrete you think a certain document is written.

Take care,

chbare.

[usmc_chris]

I completely agree with you, chbare! However, I understand what NYCEMS is saying... there is very little that is more frustrating than being presented with a signed, legal, complete living will in which the patient EXPLICITLY states that he/she would not want CPR, intubation, ventilation, etc. BUT because NYS only permits EMS to honor the DOH DNR form and the MOLST form, in the event that patient went into cardiac arrest, we would legally be bound to resuscitate.

One could certainly contact medical control for guidance in this event, however, they would most likely instruct you to initiate resuscitative efforts, at least to the point of field termination, if not insisting that we transport (we must have medical control authorization to cease resuscitative efforts in the field in my area).

[Doczilla]

My gut told me there was no foul play, and I thought it unlikely that both the husband and her father were conspiring to off her, although the husband was clearly driving the bus when it came to her care. There was no durable POA; we were just going by the usual OH rules regarding who makes those decisions, i.e., spouse, then parents, then grown children, then siblings, etc. Ethics committee is a good thought, but I'm not sure how we make that happen at 11pm on a weekend.

Ohio currently has two levels of DNR. A DNR-Comfort Care Arrest (DNR-CCA) simply states that no resuscitation will be undertaken in the case of a cardiac arrest. It is frequently interpreted to allow everything else, though we may modify treatment based on discussion with family. A DNR-Comfort Care (DNR-CC) means that no aggressive lifesaving measures will be taken. This is usually taken to exclude intubation, pressors, central lines, defibrillation, but not necessarily IV hydration, artificial nutrition, or antibiotics. There is legislation afoot in Ohio for the MOLST (Medical Orders for Life Sustaining Treatment), but at present the only way to express your wishes regarding specific treatments is in a written advance directive. As you can see, even here, there is room for debate, as some will say that brief life saving interventions would be permissible if the disease process is thought to be easily reversible.

Most patients I encounter do not have clear advance directives on what care they would or would not want, which complicates things for those of us in critical care and emergency environments. We often rely on family members to tell us what they know of their loved one to help us guide what we do. If they have no useful information, then we treat under the doctrine that most people would want to survive under any circumstances. Most of the time EMS is, frankly, not permitted to think beyond the written page. Only honoring a recent, signed, very explicit DNR order is perhaps medicolegally the safest way to go. This also fails to address the majority of futile resuscitation that we will perform. Of course, if the patient never said anything, we'll never know that they wouldn't want to suffer a lingering convalescence. Making this call on limited information, from sources other than the patient, is tough.

There is that critical time, the immediate resuscitation, that makes all the difference. If you can get someone through that initial issue in the ER, it is very likely the patient will survive. It could be that come patients see that respiratory arrest as an easy way out, and in fact, they are often correct, since the one intervention, intubation, at the critical time, is enough to get them over the hump, to a prolonged convalescence, which is what the patient may want to avoid if they have expressed their wishes not to be intubated. Does this change what we do if the causative issue is one that is potentially easily correctable, or iatrogenic, or self inflicted?

In the end, it was all academic. She maintained her own airway and did not require intubation in the ER. The patient was not terribly well educated on her insulin pump, and was also on a long-acting insulin, so it was thought that this, combined with a UTI, caused the hypoglycemia. She was admitted by PCC to the ICU. He made her a full code, and his documentation stated that he "was not satisfied with the documentation of her wishes regarding code status". The husband was apparently pretty unhappy about it, according to the chart. The patient fully recovered, and met with Integrative Care Management. In a well-documented conversation, the patient said she would not want to ever be intubated under any circumstances, and it appears the husband was correct. A DNR-CC form was executed, and the patient discharged home.

I bring this up because of the difficult position I was in, not just with the patient and family but with staff. The nurses taking care of her were very experienced and pretty headstrong, and they clearly would have put up a fight if something happened and intubation was medically indicated and I refused to do it. I'm not sure how that would have played out, but it likely would have involved the resource nurse, the AO, another physician from the ER, and hard feelings all around. It would have been fairly ugly. We like to think that we run the place, but when the nurses feel an ethical obligation to do something, they can, and will, stand up to us, and refuse to execute orders they feel are not in the patient's best interest.

'zilla

[DwayneEMTP]

Awesome scenario Doc! Thanks so much for doing that!

And as chbare said, what a gift it is that you continue to participate with us here.

Dwayne

[paramedicmike]

Thanks for making me think, Doc. This was a nice twist on a case scenario and provided an awful lot of food for thought.

[chbare]

I would have had your back doc.

Take care,

chbare.

[Just Plain Ruff]

That's a good question dwayne. I don't know how I would respond in that situation but more than likely we won't know that info at time of treatment.

Sent from my SPH-D700 using Tapatalk

[HERBIE1]

Well doc, I'm glad that the patient was able to reiterate her wishes and hopefully leave no questions as to what she wants in the future. These cases are where the doctors really earn their money, and I'm sure are the cause of a few gray hairs and sleepless nights. These types of ethical situations are where prehospital folks like us turf responsibility to a higher authority, and decisions like this SHOULD be left in the hands of someone who has access to more resources- legal consults, bringing more family into the situation, getting other medical opinions, etc.

I know what doc is saying about dealing with headstrong nurses. As anyone who has dealt with old school ER nurses knows, they can be a handful. They may look at situations from a slightly different perspective than a doctor, but in the end, the doctor makes the ultimate decision and has to face the consequences-and although any staff caring for the patient has a stake in this, the doc has the final say.

Great case, doc and thanks for making us think.

[HERBIE1]

In NYS, EMS needs to honor DNR, Living Wills, Power of Attorney, Heathcare Proxies, & MOLST. Enough is enough. No more confusion & ethical dilemnas...

There is no way that things like this are black and white. Have you ever had a patient who was DNR who presented in full arrest, and suddenly a family member on the scene questions/contests/ignores/impunes the validity of the directives on that DNR? I have had situations where a family member feels the patient was coerced into signing a DNR or ceding control of their care, and now we are put in the middle of a hornet's nest. I am not a lawyer, and that is not the time or place to debate the validity of the order, the true wishes of the patient, or what ulterior motives a family member or care giver may have. "Thankfully" in each case such as this, the patient never responded to our treatment or interventions, so the point was moot. Yes, we subjected the person's body to something they did not wish, but to me, that "person" was already gone and would hopefully forgive our interference in their final moments since our intentions were without malice. I would not feel comfortable simply standing behind a piece of paper- regardless of how "legal" it may be.

We are obligated to work the patient(contacting medical control, of course) and let the hospital sort it out when we get there. Rare, maybe, but it happens. Uncomfortable- certainly. I really wish to honor the wishes of the patient, but if there is any question as to the validity of the DNR, we have to work them.

More often, it's a case where the family panics at the last moment and questions their or the patient's choice not to be resuscitated, but generally a quick explanation/discussion clears these things up. I understand that

Issuing a DNR or any type of Advanced Directive is an abstract concept, and despite preparations by doctors, hospice, or other medical staff, the moment of death is often not pretty-ie the agonal respirations of a loved one are not something most people want to see or are prepared to deal with.

Example of a judgment call.

Recently we were called for a man in his 60's who had arrested. He was in a hospital bed at home, with a DX of terminal cancer- pancreatic with metastasis to the bone. Palliative care only. He was brought home from the hospital 3 days prior per his wishes to be under hospice care and the hospice folks were scheduled to arrive the next morning. At this point apparently he was completely lucid and competent. The doctors had given him 3 months at best to live.

In the last 24 hours he had rapidly deteriorated mentally and physically. I asked about a DNR, and the wife presented me with the original document, completely filled out with explicit details and instructions- except for her or her husband's signatures. She said they simply did not think this would happen so fast and they would have more time. She- and her adult son who was present- asked us to honor the document even though it was unsigned. The patient technically did not meet our criteria for a DOA, but was apneic and asystolic. We honored the wife's wishes and did not resuscitate the patient. Technically wrong? Yep, and I would have a tough time defending this in court should someone opt to challenge this. I would also do the same thing again in a minute- without hesitation. The wife knew her husband was gone and nothing could be done for him, but simply needed someone to confirm her thoughts.

(Full disclosure-

We actually had a connection to the patient- a coworker used to work with the wife, and we actually knew the son- he was a fire and EMS fan that would occasionally hang around houses throughout the city. They were both grateful for our discretion and even invited us to the funeral and memorial services. )