The Near-Death Patient

A dying man’s orders restrict his treatment—but what about during transport?

   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 the 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.

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