CPR or Not?

[Arctickat]

Correct: but a physician has declared the Pt deceased. No need for any intervention from EMS

I agree Ed, I just got the feeling from a couple of posts that they didn't read the articles and misinterpreted my post of an ACD to mean a DNR.

Edited March 20, 2013 by Arctickat

[ERDoc]

Seems pretty cut and dry to me. A licensed physician has declared the pt dead. Why are the firemonkies doing CPR? I wonder if the previous event had any influence on this. If I was a family member, I would make an issue out of this but then again the public sees the FD as heroes and allow them so leeway.

[Secouriste]

The responsibility isn't mine. Is shitstorm there was, it would strike well above my little EMT's head!

If I arrive on scene with a pt declared dead by a physician, I keep my bag on my back and wait for the authorization to leave. I will of course recors the whole situation in my mandatory "call report".

[Bieber]

I'd go ahead and withhold resuscitative efforts.

[MikeEMT]

I agree with those not starting CPR because the doctor has the overall authority. However, I voted to start full resucitation. As is a common saying around these parts, If it isn't on paper it didn't happen. The paperwork handed to me by the doctor and signed by both the doctor and family, states that full resucitive efforts are to be under taken.

While I fully support the Doctors' decisions and his opinion, it won't protect me in a law suit. Until I can either get the doctor to put it in writing or I can get it on a recorded line from medical control, I have to respect the written orders. Who is to say the Doctor would confirm your version of the events if it should go to court.

When in doubt always start CPR. It is easier to stop CPR than it is to start it after several minutes have elapsed. So the bottom line is, until I can get validation on something physical CPR will be performed.

Sounds like everyone did everything the way it should be. The engine crew started CPR and the Hall Ambulance Crew contacted Medical Control and got permission to terminate.

[mobey]

Ummmmm guys, an Advanced Care Directive does not necessarily mean a DNR. In this particular case, the decease had an ACD for all appropriate measures to be taken, including CPR.

To clarify, I was not talking about a piece of paper.

I meant if the patients own physician, as well as family are asking for no resusitation, then I am comfortable not bringing back an elderly person from a lodge, to put them on life support in the ICU for a few days at $25,000 a day just to feed my own interest. (estimated dollar figure there).

The other way to look at it is: A Dr. has "Called the code". I am no one to undermine him in this circumstance.

If this ws one of the 25y/o kitchen staff, I'd be singing a different tune of course. But this is not.

[triemal04]

I agree with those not starting CPR because the doctor has the overall authority. However, I voted to start full resucitation. As is a common saying around these parts, If it isn't on paper it didn't happen. The paperwork handed to me by the doctor and signed by both the doctor and family, states that full resucitive efforts are to be under taken.

While I fully support the Doctors' decisions and his opinion, it won't protect me in a law suit. Until I can either get the doctor to put it in writing or I can get it on a recorded line from medical control, I have to respect the written orders. Who is to say the Doctor would confirm your version of the events if it should go to court.

When in doubt always start CPR. It is easier to stop CPR than it is to start it after several minutes have elapsed. So the bottom line is, until I can get validation on something physical CPR will be performed.

Sounds like everyone did everything the way it should be. The engine crew started CPR and the Hall Ambulance Crew contacted Medical Control and got permission to terminate.

Ok...but why? If you are in the ER (or any part of the hospital) and a patient codes...if a doctor there say's they are done and/or not going to work it, will you disregard that and jump in?

This wasn't a random doctor off the street, or even a doctor at an urgent care or clinic; this is a skilled nursing facility with an on-site MD. The patient is under this doctor's care while they are in that facility. The doctor responsible for their care is making the decision to not attempt a resuscitation, and has been in consultation with the patient's family. Explain your thought process please.

I get that you might be uncomfortable making that decision, but if that's the case, why not take your own advice; contact your medical control, explain the situation and let them make the decision. Even better, if you are that worried, contact the family, confirm it, then contact your medical control, let them talk with the facility doc, and then go from there.

And keep in mind that this was not a simple case of the fire department and ambulance doing CPR until they could reach their medical control; I can understand why that would be done even if I disagree. These guys worked a full resuscitation and only called after it was unsuccessful. Poor form I'd say.

[MikeEMT]

Ok...but why? If you are in the ER (or any part of the hospital) and a patient codes...if a doctor there say's they are done and/or not going to work it, will you disregard that and jump in?

This wasn't a random doctor off the street, or even a doctor at an urgent care or clinic; this is a skilled nursing facility with an on-site MD. The patient is under this doctor's care while they are in that facility. The doctor responsible for their care is making the decision to not attempt a resuscitation, and has been in consultation with the patient's family. Explain your thought process please.

I get that you might be uncomfortable making that decision, but if that's the case, why not take your own advice; contact your medical control, explain the situation and let them make the decision. Even better, if you are that worried, contact the family, confirm it, then contact your medical control, let them talk with the facility doc, and then go from there.

And keep in mind that this was not a simple case of the fire department and ambulance doing CPR until they could reach their medical control; I can understand why that would be done even if I disagree. These guys worked a full resuscitation and only called after it was unsuccessful. Poor form I'd say.

This is a doctor at a SNF. Who knows what protocol they use to determine death. A strip would want to be seen by the docs. I have yet to see a SNF have a 12 lead. Obvious signs of death excluded, this is a case that would require at least a strip sent to the Medical Control doc to make the call. Just because there is a "doctor" on scene doesn't automatically grant him the authority.

Now as I said, I fully respect the on scene doctors opinion. More so if he IS the primary care physician for this patient and NOT the SNF staff doctor, which I have not been to impressed with from the ones I have seen.

Here in the US we are a very sue happy society. People will sue for just about everything, and often us EMS professionals are caught in the Middle. When I was doing investigations I saw people lose everything because of law suits. I work hard for my house and my possessions. I may not be rich, but I am proud of what I have and I am not going to sacrifice that in a lawsuit. In court there is Hearsay and Physical Evidence. Of the two, Physical Evidence carries a lot more weight.

You go on this call, a doctor tells you that he just got off the phone with the family and they don't want CPR started. You listen to the doctor, do your PCR and go back to quarters. 5 years later your called to court and you have to testify why you did not do any CPR. You refer to your PCR and say that Dr. Smith said he spoke to family and to not perform CPR. Now this attorney pulls out the signed Advanced Directive which was signed a couple days prior to event. This document indicates that full resucitation efforts - including hospital transport - are to be undertaken. What do you think the jury is going to side with? Do you think the Doctor is going to remember talking to you or the family? Do you think he will remember what was said? What if the family didn't have Power of Attorney? Just because its a son or daughter doesn't mean that they were on good terms. There are plenty of parents who are estranged from their kids. Their are plenty of kids who do not have their elderly parents' best interests in mind for whatever reason.

Start CPR while your partner contacts Medical Control. 30 seconds on the phone with them and you will likely get your confirmation. You will have a recorded record of the authorization not to mention a strip. You did the best for the patient, which according to the signed document was to perform CPR. Worst case you perform a few minutes of CPR while getting the authorization. In the process you have protected yourself, your crew, and your agency.

I can care less about a SNF or the Doctor working for a SNF. I am not sacrificing my certification nor my families well being based solely on Hearsay. It may be worth it to you, its not to me. The signed document holds more weight than the verbal authorization from a doctor on scene.

Now if family were present...eh, I don't know. That would be a tough call. Again, I think I would side with the signed document until I got medical control authorization.

Bottom line is this - I may just be a basic but I worked my a$$ off to earn that title. I am going to protect it.

As I said earlier, I don't fault anyone for NOT performing CPR in this case - me personally I will do it though for the reasons stated. Excellent discussion.

Edited March 21, 2013 by MikeEMT

[BEorP]

This is a doctor at a SNF. Who knows what protocol they use to determine death. A strip would want to be seen by the docs. I have yet to see a SNF have a 12 lead. Obvious signs of death excluded, this is a case that would require at least a strip sent to the Medical Control doc to make the call. Just because there is a "doctor" on scene doesn't automatically grant him the authority.

Why are we calling the doctor a "doctor"? Did I miss somewhere where his credentials were questioned? A doctor does have the authority to pronounce death and they are certainly not required to following any ambulance services protocol for how they do this for their patients.

[ERDoc]

Doctors don't work under protocols, they use medical judgement. I would have a huge problem with anyone starting CPR in this case if I had already pronounced the pt. It becomes assault/decimating a corpse/whatever your state law calls it at that point and I sure as hell would push the point with your medical director and/or state medical director. It has nothing to do with ego and is all about dignity for the pt and family.