The Near-Death Patient

   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.

INITIAL ASSESSMENT

   An 88-year-old male with failing respiratory and circulatory status.

   Airway: Intact.

   Breathing: Slow respiratory rate.

   Circulation: Perfusing poorly; pale skin, delayed capillary refill, cool to touch.

   Disability: Does not respond to verbal or painful stimuli.

   Exposure of Other Major Problems: Patient and family do not want resuscitation.

VITAL SIGNS

Learning Point:

   Hospice patients require medical protocols, with an understanding of state regulations on limited medical treatment, comfort care and who is allowed to pronounce death.

Customer Service Opportunity

   EMS protocols for end-of-life decisions and processes must be established, consistent with state laws and regulations. Educational programs for EMS personnel are best when matched with outreach efforts to help educate local physicians, especially those who have patients with terminal illnesses. Families and community groups like faith-based organizations must be educated as well. Patients and families will be much more comfortable with policies to forego resuscitative efforts when they are assured comfort care can be provided and that their wishes will be honored. A grief support program to help family members in all instances where death has occurred will provide additional comfort for rescuers and those contemplating use of limited-treatment programs.