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?

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Joe,

 

For my system, it would require medical command permission to cancel the call and switch it to an interfacility transport, but that might be a way of making it acceptable to the medical command doctor. The patient is being transported to the facility the patient/POA wants the patient top go to, unless the patient/POA wants the bradycardia/hypotension treated in an ED. I am comfortable assuming that is not the case, because the result of the scenario was that the patient was transported to hospice.

 

As I stated, flexibility and gathering information is important. There are things that I may not think of that may work very well. I have contacted the patient's physician and discussed what might be done (advised the doctor to remain available for maybe 10 minutes, in case the medical command doctor wants to talk directly with the patient's doctor. Then I have contacted medical command and explained what I discussed with the patient's doctor. It is important to reach a medical command physician interested in doing what is right for the patient.

Joe,

 

I was trying to edit my post and it wasn't letting me. I copied it, deleted the original, and pasted it again. I only changed a couple of sentences.

 

Either that, or you have awesome psychic powers. ;-)



Rogue Medic said:

Joe,

 

I was trying to edit my post and it wasn't letting me. I copied it, deleted the original, and pasted it again. I only changed a couple of sentences.

 

Either that, or you have awesome psychic powers. ;-)


The difference between psych patients and medical students on a psych rotation is who has keys to the unit. Of course my pysch rotation is about 7 months away.
DNR=Do Not Resuscitate, not Do Not Treat... This topic has been beat up beyond recognition, so I'll leave it at that.

Hospice calls are a very delicate subject. We know what the outcome will be but it doesn't negate treatment. ALS Care can be rendered; so as long as everyone relating to the patient agrees. In a Non-Emergency setting; our Regional Protocols are not in effect because this is a Hospice Case. In my system; they will fall under Discretionary Protocols (No Protocol exists). Full autonomy, will be the best way to care for these patients. Obtain good history and exam; an IV can be start to aide in hydration; as long as the patient has good veins. Poking the patient for the sake of poking is unethical. Have OLMC decide if you gan give MSO4 for pain. In my experience; many MDs will give that order.

 

My company does a lot of transports from the home or Nursing Home to Hospice Care. If you gain access because the patient looked dehydrated, emaciated, or in distress; you just made it easier for the Hospice Care Team to order and administer the Opiate for comfort. However, the patient must agree on this. They've earned the right to die in their own terms. DNR, DNI, Living Wills, Power of Attorney, MOLST, and other Advance Directives just makes the situation EMS is in, worst; we're always stuck between an ethical dilemna. As the Paramedic, you should be providing the care; BLS or ALS, for this call. Give the patient the potiential option for Advance Care, if he/she should change their mind. They deserve that from you. All the best...

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