Limited Engagement

Attack One’s dispatch is for a man with difficulty breathing, but the crew is told the call came from a family who believes their father has died, and they just want someone to come and pronounce him dead. They’ve been told the funeral home can’t come to remove his body until that has taken place. When interviewed, though, family members say they think the man is still breathing at times.

The crew is greeted by the family and taken to a second-floor room where a frail man lies in a bed. He is very pale, but warm to the touch. He is breathing slowly, and the pulse oximeter records an oxygen saturation of 92%. He barely withdraws from painful stimuli. The family produces a document from the man’s hospice physician ordering he be provided “comfort care” only. The physician expects the patient to die soon, from cancer and complications, and has discussed that process with the family. The orders to limit emergency treatment were written at that time, and a hospice nurse has been to the house to discuss them and provide ongoing care to the patient. She’s not at the home today, however, as it is a holiday weekend.

The son explains that the patient, 88, had been eating until yesterday. The hospice nurse saw him then and advised the family he would likely live for another week. The family wanted the patient to be at home for the holiday weekend, but they and the nurse planned to move him to the hospice inpatient facility once it was over. As the patient became unresponsive, the family tried to reach the nurse by phone, but she is not available. They are distressed the patient has deteriorated so quickly, and that they incorrectly identified him as dead.

The patient is breathing slowly, and has a very weak and slow pulse. The paramedic asks the family to call the physician who’s caring for him. As they await his return call, the oldest son requests the crew remove the patient to the hospital. They move him gently to the stretcher, and ask the family to have the physician call the hospital where they’ll be taking him. The paramedic takes the paperwork related to limiting treatment to pass on at the emergency department.

“What will happen if he stops breathing on the way to the hospital?” the daughter asks.

The paramedic feels comfortable explaining the process by which they crew honors orders to limit treatment: “We will follow those orders, and will not start any treatment if he stops breathing or his heart stops beating,” he tells the family. “Otherwise, we’ll give him some oxygen by mask and make sure he is comfortable”

“And if he dies,” the daughter asks, “you will pronounce him dead and take him to the funeral home?”

That’s a question worth thinking through. This man has very slow respirations and a slowing pulse. He could well die in the time it takes to get to the hospital. The medical protocol calls for limiting treatment in line with a patient’s written wishes, but is not explicit on what to do when a patient is being transported. Some hospitals will not accept patients who won’t be receiving any care. But in this region EMS ambulances do not transport to funeral homes.

“No, ma’am, we cannot pronounce patients dead,” the medic tells her. “We would take him to the hospital and let the emergency department doctors do that, contact his physician and make arrangements with a funeral home.”

Everyone hopes that doesn’t happen, but the transport is barely underway before it does. The paramedic had called ahead to the ED to advise them of what was going on. He explained the circumstances to the emergency physician and asked what the options were if the patient lost his pulse before they arrived. The physician reinforced that the crew should not initiate resuscitation, but that transport could continue, and the ED would manage the pronouncement and subsequent steps.

Within 60 seconds, the patient’s rhythm slows dramatically, and his breathing becomes agonal. Confident about the next steps, the medic asks the driver to pull over, so they can let the family be with the patient as he expires. The family is following in their car and pulls in behind the ambulance. The paramedic asks them into the patient compartment, and they sit with the patient as his rhythm converts to a straight line and his breathing stops.

Case Discussion

All human beings must die. This is a natural course of events, and emergency medical personnel are not expected to perform miracles. However, they must follow certain laws and guidelines in regard to managing end-of-life patients and avoid repercussions for the department and family members.

This case demonstrates a course of action that offers a dramatic improvement in patient care. Terminally ill patients and their families can now control their treatment through state-specific processes, including limited-treatment plans. A full discussion of these plans is beyond the scope of this article, but there are clear needs for their use by emergency personnel. The limited-treatment plan calls for a discussion to occur between the terminal patient or appropriate proxy and their private physician. That physician then writes a medical order to limit emergency treatment.

Normally, once resuscitative measures are instituted, if unsuccessful, they must be continued until a physician has pronounced the victim dead. Many EMS systems have developed policies for field termination of resuscitation, with appropriate involvement of medical control. A family member’s involvement can facilitate this process, even in the event of missing or procedurally defective documentation (e.g., an out-of-state form, a signature on the wrong line or a document past its renewal date). The ability to contact medical control may be reassuring, but does not substitute for providing EMS personnel reasonable standards and expecting them to make reasonable decisions.

Hospice and other end-of-life treatment programs have become more popular and are very helpful to terminally ill patients, their families and the physicians who treat them. Some states have developed laws to allow a broader range of providers to assist in the dying process. In those states persons expected to die outside a hospital may have an attending registered nurse sign the pronouncement of death section of the death certificate.

There are many ongoing issues related to the near-death patient. EMS agencies have a related responsibility to embrace realistic goals and expectations in resuscitation attempts. Views of hospice and other end-of-life care have evolved rapidly, particularly with concerns about healthcare cost efficiency. Present laws are an important first step in guidance for emergency personnel in end-of-life events.

A strong educational component is also needed. EMS personnel should be prepared not only to identify when resuscitation attempts are and aren’t indicated, but also to provide appropriate support to patients and families.

Specific policies related to matters of death, near-death and use of limited-treatment plans must be coordinated with legal and medical advisors.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. He is also a member of the EMS World editorial advisory board. Contact him at jaugustine@emp.com.