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Scenerio that has me stumped.
Ok this is a real scenerio that I know the techs who were involved. It goes like this.......Home hospice RN has a patient that is to be transfered to the local hospice house to live out his last few days, she has arranged for a local transport service to transfer the patient. While waiting for the time to roll around that the service tells her they will be there by and the patient begins to deteriorate. No radial pulses, very weak and has a carotid only, Bradycardic @46, BP of 60/p, patient is a DNR. Home hospice RN calls 911 because she is tired of waiting for the transfer service and doesn't want the patient to die on her at his home, well the call goes out and EMS and 1st responders arrive to find out the RN only called for transport because she was tired of waiting on the transfer service.
The local EMS service is a Type 1 service with type 2 capabilities so we staff each unit with a medic and an EMT, the medic on the call allows the EMT to tech the call to the hospice house. Now, my question is, and I'm a medic BTW and I know what I would have done but that's not important, my thinking is that since this RN called 911 she's activated the EMS system and even though this patient has a DNR and is going to be transfered to hospice house in my opinion this should have been an ALS call even though they were only called for a transfer.
If this had been an arranged transfer through either hospice house for EMS to transfer or if he was an in-patient at a hospital and they arranged for EMS to transfer him then I could see it being ok for the EMT to tech but for some reason I can just see this become a HUGE QA issue, what do you all think?
The local EMS service is a Type 1 service with type 2 capabilities so we staff each unit with a medic and an EMT, the medic on the call allows the EMT to tech the call to the hospice house. Now, my question is, and I'm a medic BTW and I know what I would have done but that's not important, my thinking is that since this RN called 911 she's activated the EMS system and even though this patient has a DNR and is going to be transfered to hospice house in my opinion this should have been an ALS call even though they were only called for a transfer.
If this had been an arranged transfer through either hospice house for EMS to transfer or if he was an in-patient at a hospital and they arranged for EMS to transfer him then I could see it being ok for the EMT to tech but for some reason I can just see this become a HUGE QA issue, what do you all think?
Replies to This Discussion
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Permalink Reply by Ken Roberts on -
Valid DNR I think I would have called command and allowed them to make the decision. I don't assist anyone schedule when someone else can die and when they can't. I believe that RN should have been investigated for breaking her protocols as well. Definately a screwed up mess of a call though.
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Permalink Reply by Doc82 on -
Jason, excellent topic for discussion.
You said the RN called 911, yet there was a valid DNR. So let me ask this, with the valid DNR, and you being provided the DNR, you said this should have been an ALS call, yet what beyond the BLS level would you have been able to do? I agree that it was an ALS call and the Medic should have teched instead of the EMT for legal reasons, and without the DNR in hand and/or verified through Med control, It would have been run as an ALS call. Yet, with the DNR you can not provide recusicitative care.
Regardless of who techs it, after the run, Med Control, and supervisors would have been informed of the situation as IMO that's an abuse of the 911 system.
We had a somewhat similar run a couple of years ago. I was on a 911 truck that got dispatched to a home for an elderly male with difficulty breathing. When we got to the home, the home health tech said there was a DNR, yet was unable to provide it. She told us that the hospice nurse had been called and that she (the hospice nurse) had a copy of the DNR with her. We contacted our Med Control who told us without the DNR in possession we had to work it. Needless to say the DNR was delivered to the ER later, but that was out of our hands.
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Permalink Reply by Kevin Dunbar on -
Well, In our neck of the world if you call us 911 we only transport to a hospital, as far as the emt taking the call I probably would not have the emt take the call, did the pt have any iv's pain meds or anything else? Then on the other hand if you are not doing any als comfort measures I guess it really does not matter who rides in the back, but I think I would have the patient on the cardiac monitor for documentation.
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Permalink Reply by Jason on
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Doc82 said:Jason, excellent topic for discussion.
You said the RN called 911, yet there was a valid DNR. So let me ask this, with the valid DNR, and you being provided the DNR, you said this should have been an ALS call, yet what beyond the BLS level would you have been able to do? I agree that it was an ALS call and the Medic should have teched instead of the EMT for legal reasons, and without the DNR in hand and/or verified through Med control, It would have been run as an ALS call. Yet, with the DNR you can not provide recusicitative care.
Regardless of who techs it, after the run, Med Control, and supervisors would have been informed of the situation as IMO that's an abuse of the 911 system.
We had a somewhat similar run a couple of years ago. I was on a 911 truck that got dispatched to a home for an elderly male with difficulty breathing. When we got to the home, the home health tech said there was a DNR, yet was unable to provide it. She told us that the hospice nurse had been called and that she (the hospice nurse) had a copy of the DNR with her. We contacted our Med Control who told us without the DNR in possession we had to work it. Needless to say the DNR was delivered to the ER later, but that was out of our hands.
I should have stated it would have been for legal reasons as to why I would have teched the call myself and not let the EMT, I totally understand that with a valid DNR order as a medic there would be nothing more I would do than an EMT-Basic would do in the event of the patient going into cardio/resp. arrest.
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Permalink Reply by Chance Gearheart on -
The medic should be smacked for inappropriately downgrading care. A DNR does not mean Do not treat.
In addition, should this patient pass away, then the medic must pronounce.
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Permalink Reply by Jason on
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Chance Gearheart said:
Exactly, transfer to hospice or not I myself think it should have been teched by a medic.The medic should be smacked for inappropriately downgrading care. A DNR does not mean Do not treat.
In addition, should this patient pass away, then the medic must pronounce.
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Permalink Reply by Melissa on -
I agree that the medic should have taken this call, if nothing else, to be able to give pain meds or IV if the pt needed it. I have more of a problem with the nurse calling 911 though. I have worked with Hospice several times. Both with family members and with pts of mine. I have never heard of them calling 911 and they informed us NOT to call 911 unless we had talked to them. Why did she have a problem with the pt dying at home? Usually that is why they are at home with hospice, to die at home and in peace. That just doesn't make sense to me.
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Permalink Reply by Russell Stine on -
I wouldn't have transported, just turned it over when the transport got there. EMS should never have been called because this is clearly not an emergency. The patient has a wish to die without intervention, let it be so.
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Permalink Reply by Liz on
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As in all ethical issues, you have to contact the local medical control in order to CYA, and help alleviate any future QA problems. This determining factors are also mandated, by the amount of hospice patients in an area, the amount of Hospice services that serve those patients, and the comfort the general communities have with those services. The EMS staff, having contact with both the hospice service and the hospitals, will be able to build relationships with both entities that will allow them to work together to meet the needs of all involved. When the 911 system is activated, we all want to throw the "DNR" status out the window, however, we must not only care for the patient but also the caregiver. In many instances, the caregiver, or the hospice nurse that calls, does so in order appease the family, or so they are not alone. We must always keep in mind that the DNR order must be in place, and if the patient signed it themself, it must be adhered to, as it was signed when they were healthier and thinking clearly about thier end moments. Even if it is signed by a Durable Medical Power of Attorney, we must take that into account. The over most important thing is if the family asks that we make attempts to resuscitate, then we do.
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Permalink Reply by TheCannulator on -
The man is dying. Do what ever he needs to let him die with dignity.
(I don't understand the "EMT to Tech" thing seeing I'm out of town.)
Keeping a dying man waiting should be the focus of investigation.
What skill set do you need to let someone die? What skill set do you need to give someone dignity? why did they need ALS care?
Yep we might get a bit dark because the nurse couldn't be bothered waiting, but really we can just get over it and look at ways of supporting the dying instead of using them as points to score by.
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Permalink Reply by kristen on -
DNR means do not resuscitate, it does not mean do not treat. this person has a pulse and a bp, therefore they need to be treated appropriatly and transported ALS. If they code enroute, dont resuscitate as long as the DNR is valid and legal. up to the point where they code, they should be treated as would anyone with the vitals as listed. and since 911 was called, they should be transported to the closest hospital. once that call is initiated and EMS arrives, that patient becomes theirs, not the Hospice RN's because by calling EMS she has turned over patient care.
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Permalink Reply by kristen on
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Hospice nurses call 911 all of the time. DNR is not to be used not to treat people. If they are septic, dehydrated in pain ect.. and the hospice nurse is unable to provide the appropriate care, then the patient needs to be transported to the hospital, where they can recieve comfort measures, antibiotics, fluids, meds. dying humanely is dying while still having basic needs met. are you suggesting that someone unable to eat should die of starvation rather than their disase?
Melissa said:I agree that the medic should have taken this call, if nothing else, to be able to give pain meds or IV if the pt needed it. I have more of a problem with the nurse calling 911 though. I have worked with Hospice several times. Both with family members and with pts of mine. I have never heard of them calling 911 and they informed us NOT to call 911 unless we had talked to them. Why did she have a problem with the pt dying at home? Usually that is why they are at home with hospice, to die at home and in peace. That just doesn't make sense to me.
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