Pinnacle: Caring for End-of-Life Patients

Power Seminar Speaker Spotlight: Scott Bourn, PhD

Whether you’re a brand new EMT or veteran physician, it’s critical to keep up with the latest clinical research to ensure you are providing the best care for your patients. Journals like Prehospital Emergency Care and JAMA are excellent resources for this material. Some research papers can be dense and time-consuming to read—reading them cover to cover in the hopes of digesting and retaining every bit of knowledge from them is a flawed learning methodology, said Scott Bourn, PhD, in the Pinnacle EMS conference power seminar session, “Clinical Best Practices 2019 and Beyond: The Latest Research and How It Impacts Patient Care” in Orlando, Fla. on July 22. Instead, he recommends skimming the paper, identifying the content that’s pertinent to your patient care, and asking yourself, So what?

Joined by a line-up of speakers Peter Antevy, MD, MPH, Brad Lee, MD, JD, David Page, MS, and Ed Racht, MD, Bourn reviewed “Decision-Making in the Moments Before Death: Challenges in Prehospital Care,” a paper published in Prehospital Emergency Care. The research examines EMS providers’ experiences with treating patients nearing the end of life and their keen awareness of how their clinical decisions impact the patients’ families. The management of these scenarios partially depends on a family’s awareness of their loved one’s documentation of end-of-life wishes (or lack thereof), which can put providers in difficult positions when the patient’s wishes are unclear, undocumented, or not aligned with the family’s. Even when a DNR is present, family members may still request EMS to resuscitate in the heat of the moment. The paper names four decisional contexts EMS providers face in the field:

1. Awareness of dying-wishes documented: Families were prepared but needed support and validation
2. Awareness of dying-wishes undocumented: EMS required to begin treatment under the guidance of medical control
3. Unaware of dying-wishes documented: Families in shock and assumed EMS could prevent death
4. Unaware of dying-wishes undocumented: Families were frantic and not prepared

When EMS professionals arrive on scene to a patient nearing death, they’re expected to treat the family with respect and decide whether or not to resuscitate the patient based on their wishes, if documented, or the family’s wishes, if not documented. The latter case can be difficult to act on if family members have conflicting wishes for their loved one (whether or not their dying-wishes are documented). It’s up to providers to determine the most appropriate clinical decisions under these complicated and sensitive circumstances.

The research methodology utilized for this paper is different from others in that it was focused on qualitative metrics, such as the feelings, attitudes and performances of prehospital providers, as opposed to quantitative metrics. Bourn said qualitative studies lead the quantitative ones because they help us understand themes that can point to areas to be explored quantitatively. However, there are some drawbacks—surveys with multiple choice answers presume that researchers know all of the potential categorical answers to their questions, which they don’t, resulting in the possible exclusion of important information. While surveys with open-ended questions are ideal because they encourage comprehensive responses, this route requires researchers to do much more work.

“Most fallible research is contextual,” said Bourn, commenting on how conducting randomized, controlled trials in the context of EMS is problematic because EMS scenarios are not controlled and are rather dynamic. Crews will inevitably encounter any one of the given four decisional context scenarios, so preparation for their management is a must. Providers should learn how to effectively and compassionately communicate with families about end-of-life care.

“It’s not what you say, it’s how you say it, and how you communicate it to different populations and cultures,” said Bourn. Asking a question like, ‘Do you want to violate their wishes?’ could help put things into perspective for family members who want you to resuscitate their loved one despite them having a DNR. Aim to minimize risk and litigation, and mitigate discordance. The more discord, the more stress for the providers, said Bourn, both in prehospital and hospital settings. The ED and EMS need to be aligned in their thinking and approach to handling end-of-life patients and their families. If they’re not, an integrated system must be created so families aren’t further distressed by receiving conflicting information from the medics and physicians.

Ultimately, we must equip our providers with the skills to manage end-of-life care scenarios: how to offer support to the patient’s family members, de-escalate disputes between them, and make sound clinical judgements despite the involved stressors.