First Responders and the 'Silver Hour'

Death is a reality for EMS personnel. Patients come to the ends of their lives in many ways. Most arrive at death from chronic illnesses. Others succumb to severe trauma. Because of the importance of first responders understanding how to care for someone at the end of life, the new National EMS Education Standards specify that EMTs and paramedics be educated to meet the end-of-life needs of terminally ill patients and their families. Urgent care is required when patients die. Paramedics also require additional training to understand how to address the needs of patients and their families when resuscitation is withheld or terminated.

We use the concept of a "silver hour" to describe the unique needs of patients in the time just preceding their death and the needs of their family immediately upon the patient's death. The silver hour complements the golden hour, well known to emergency responders. The golden hour was derived from analysis of medical records in World War I. Records indicated that when care was prompt--i.e., within 60 minutes of trauma--there was a significant increase in survival. In the silver hour, 30 minutes before and after death, healthcare workers act with the same urgency, competence and compassion used for other life-threatening situations. However, the focus is on a peaceful death and supporting family needs.

At Moreno Valley Community College in Riverside, CA, as much attention is paid to end-of-life care as other paramedic care skills. Initially, we've begun working to develop the expertise of paramedics in coping with the prehospital death of terminal patients. In the future, the curriculum will include many more types of death paramedics encounter. The education has one simple message: Care is not over when the patient dies!

Paramedics and first responders are well acquainted with death; approximately 10% to 15% of emergency calls are for patients with terminal illnesses.1 Increasing numbers of geriatric patients amplify the probability of patients being found dead or dying shortly after responders' arrival. With an emphasis on shorter hospital stays, patients are often being discharged home with intermittent support from skilled healthcare workers such as home care and hospice. Other patients may be offered services but decline to use them, choosing instead to rely on elderly caregivers, neighbors or family. These complex situations can lead to calls where there is conflict or uncertainty in the patient's preferred treatment plan.

In addition to asking the family about the name of the primary healthcare provider/physician, paramedics should also ask what other services the patient is receiving or anticipating receiving in the home. Common services include skilled home care for patients who are expected to recover from their illnesses but who require treatments such as intravenous lines or other complex care. Palliative care may be offered to patients who have life-limiting diseases (i.e., death may occur within a year). Hospice services are indicated when patients have terminal conditions (i.e., if the disease follows its normal course, the patient will die within six months). With any of the services, the patient may have opted to allow a natural death. That term is now preferred over "do not resuscitate" (DNR). Allowing a natural death means CPR will not be initiated. Only comfort care will be given to the patient.

Here are some tips for discussing what the patient's wishes are at the end of life:

• Ensure the patient's wishes are honored, including advance directives and stated end-of-life desires.
• Inform family members of, and include them in developing, patient-centered treatment plans on scenes.
• Ensure family members are assessed for signs of ineffective coping, and seek support to help them.
• Contact, or ask a family member to contact, all existing healthcare providers.
• Speak directly to those providers whenever possible.
• Home care and hospice providers leave charts in the home that list medications and other important information, such as 24-hour contact numbers. Leave your own contact information in the chart.