Let Me Die: Honoring People`s Other Right

     EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don't have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. We don't know everything, but we do know a lot of smart people. If we need to, we'll contact just the right experts and share their advice with you. E-mail ideas to Nancy.Perry@cygnusb2b.com.

     Bud Gradishaw is a tough old guy, that's all. He's a Marine veteran of more than one battle in the Pacific, including the brutal struggle at Guadalcanal. He doesn't talk much about that, but you know from past encounters with him that he was a private in an infantry division. Now, his female companion has called you to his little bedroom in her home, and as you approach him you're struck by the fact that he doesn't look so tough anymore. In fact, today he seems small and frail.

     You bend over him and address him by name, but he doesn't answer. He's warm, apneic and pulseless. The skins are normal, the pupils are mid-positional and non-reactive, the joints are supple and there is no lividity, but the ECG reveals a sinus bradycardia with a rate of 50 and no ectopy. Your protocols call for you to resuscitate, unless there is an original copy of a Do Not Resuscitate order. When you ask the tearful companion about that, she gives you a confused look and shakes her head. But she makes it clear, Bud has been fighting lung cancer for the past nine months and has suffered a lot. He's said his good-byes, and he's ready to die.

     You try to contact your medical direction for a decision, but the physician is busy, so you wait. Then you wait some more. You hang up and redial your call, but the answer's the same: Dr. Kilmer will come to the phone as soon as he can. Meanwhile, you haven't started CPR.

     Q. Looks like you're going to have to make a decision here. This situation isn't covered very well in your protocols. You've disciplined yourself to act in the best interests of patients. What exactly does that mean, in this situation?
     A. People have a right to live. But they also have a right to die--with dignity. A good way to handle this situation would be to ask if the companion or anyone on the EMS team has any objections to withholding resuscitation, despite the fact that there is no DNR document. Remember, protocols are guidelines intended to benefit most people most of the time. You should always reserve the right and take the responsibility to think and act based on your interpretation of the situations you encounter.

     Q. You don't get any argument from the companion. But what if another team member objects to withholding resuscitation?
     A. By all means, respect their judgment and initiate the procedures. Continue until you get through to your physician, or consider contacting a physician at another hospital. Remember, your team members are also responsible for thinking, even if they have less experience than you do. None of you can be expected to have all the answers all the time, any more than the folks who wrote your protocols.

     Q. What about that companion? She hasn't said she's the patient's wife. What say does she have in all of this?
     A. The world is full of people who have no surviving family members. Although they may have no legal authority to act on people's behalf, close friends warrant our respect. This lady obviously shares the caregivers' commitment to Mr. Gradishaw. It's not difficult or inappropriate to treat her with deference.

     Q. The caregivers in this example seem to be wasting a lot of time making decisions. The brain dies in four to six minutes after the vital signs fail. Shouldn't resuscitation be initiated immediately? Philosophy is a luxury when someone is dying.
     A. That would be true if our job were to treat protocols, but we don't. Instead, we serve people. Medicine would be easy if all the answers to people's needs were simple enough to be written down somewhere so they could be referenced or memorized.

     Of course, they're not.