The first call of the morning often finds ways to test a crew before all the neurons are awake. The Attack One crew has just taken report from the overnight shift and is beginning to check the equipment when they are dispatched on a "woman down." The crew is greeted at the door and taken to a first-floor bedroom, where a very thin elderly woman is lying in bed. The family relates that she fell off the bed and injured her arm when they tried to roll her over and change her sheets. The distraught daughter is crying, feeling she has injured her mother in a way that will take her out of the house, where her mother had requested to stay until she died.
The patient is lying quietly on the bed, nonverbal and in no apparent pain. She appears ill, and the son-in-law tells the paramedic she's 90 years old, has a long history of heart disease, and was diagnosed about six weeks ago with lung cancer. She is deteriorating rapidly, but the family is fulfilling her request to keep her at home, and she has been pain-free for weeks. Over the last few days she has stopped eating, and her primary physician visited yesterday and told the family she would likely die within a week.
The patient is cared for by her family, with some assistance from a visiting nurse. This morning the daughter turned her on the edge of the bed to get her off some wet sheets, and the patient rolled onto the floor, and her wrist snapped. The bed is only about 16 inches off the wood floor, so no other injury occurred, including to the head. The right wrist has an obvious closed fracture, with no compromise of neurovascular function distal to the injury.
The patient will not speak, but opens her eyes a little when spoken to. She is in no distress when they check and splint the wrist. She appears mildly short of breath, has very pale skin and is extremely thin. The son-in-law reports this has been her state for the last few days, and nothing unusual is occurring this morning.
The daughter, talking with the crew leader, is concerned that her mother be cared for appropriately. Her mother completed a set of documents with her primary physician when she was diagnosed with the cancer, and these expressed her wishes to receive only "comfort care," while remaining at home with her family. Her daughters had offered to keep her in the house and were providing most of her care, with a little nursing assistance and occasional visits from the doctor.
"What would you like us to do to care for your mother?" the paramedic asks.
"Can you just splint her arm and leave her here?"
"No, ma'am, we will need to take her to the hospital."
The daughter begins to cry again, as her mother had made it clear she wanted to remain at home. Her documents included an order to limit treatment, including a request to not resuscitate. The daughter is concerned that taking her mother to the hospital would mean that request would be ignored, either by the EMS crew or in the emergency department.
"No, ma'am," the paramedic explains, "we will respect her request. Our orders allow us to honor those requests and provide comfort care only. At the emergency department, they will also follow the document, and will likely be able to care for her arm without doing surgery or admitting her to the hospital. She will receive pain medicine if needed, and we will move her very carefully and give her some oxygen if she needs it, but not do any other procedures."
This is an enormous relief to the daughter. She and her husband call the primary physician to advise him what's happened and confirm the hospital to which she should be transported.
They splint her arm carefully and place her in a slightly upright position for her comfort. She appears in no pain. The short trip to the hospital is done at low speed to avoid making her any more uncomfortable. The crew had noted a low pulse oximeter reading on her assessment, so they provide oxygen by cannula, which improves the value and seems to make the patient a little more comfortable.
The paramedic calls ahead to the ED to advise them of the nature of care being provided and the upset daughter. The emergency nurses greet the patient and family on arrival, take note of the daughter's concerns and the paperwork, and advise the family they will treat the patient with great care, make sure she is not in pain, and honor the wishes expressed in her limited-treatment order.
As the Attack One crew completes their paperwork, the patient is wheeled to x-ray, and the physician asks the crew to look at the results with him. The patient's fracture is significant, but will not require surgery or manipulation. Her bones are very osteoporotic, and very little trauma will fracture them. The primary physician had called the ED and requested that no other lab testing be done on the patient, and that she be released home—he will follow up on her arm. He confirms that no other measures will be taken, and that his previous discussion with the patient and her family would guide her end-of-life care. He has already prescribed morphine for her at home, and the family is familiar with the dosing schedule.
Before leaving, the crew takes a moment with the family to compliment them on their care for their mother and respect for her wishes. They suspect the daughter may be feeling guilt for allowing her mother to drop off the bed and having her taken from the house.
"We noticed what great care you're giving her, and that you're doing everything you can to keep her clean, comfortable and peaceful," they tell the daughter. "It appears you're doing a fabulous job, and we're sure this is just what your mother wants. She is very fortunate, and it appears she will be able to have her wishes fulfilled. We wish everyone could be that fortunate."
In a note to the department chief two weeks later, the family advises that their mother died about three days after returning home. Remarkably, she woke up about an hour before her death, asked what day it was, and noted it was her anniversary and that she was glad she was in her home. She went back to sleep, and about an hour later quit breathing. The family thanked the crew for their compassionate care and support for the patient's wishes.
This case demonstrates the use of paperwork that offers a dramatic improvement in patient care. Terminally ill patients and their family members have a new ability to control their treatment through documents, including living wills, durable powers of attorney and limited-treatment plans. Full reviews of these documents are beyond the scope of this article. However, there are clear directions on their use for prehospital emergency medical personnel.
Durable powers of attorney relate to a decision made by a patient to have someone else control their legal decision-making once the patient has lost the capacity to do so. This means a person with a terminal illness, understanding that the natural course of that illness will lead them to a state where they cannot make their own decisions, assigns that responsibility to another competent individual. That individual then makes decisions in place of the patient, including decisions about resuscitation and ongoing care. Durable powers of attorney have no immediate control over resuscitation decisions for prehospital personnel, but may allow a competent individual to authorize a limited-treatment order for an incompetent patient.
A living will is a document drafted by a competent individual and their attorney that guides healthcare in nonemergency circumstances. In many states, legislation specifically excludes living wills from control over emergency circumstances. The implications for prehospital providers can only be relative in nature. A living will presented to prehospital providers at the time of a call cannot control a decision to resuscitate. It can be added to the documentation taken to the hospital by the prehospital crew, and will lend support to decisions made once the patient is in the ED.
The limited-treatment order has been made available by supportive legislation in many states. The limited-treatment plan calls for a discussion between the terminal patient or their proxy and their private physician. That attending physician then writes a medical order to limit emergency treatment. This document is recognized by the emergency service provider as being a medical order to perform or not perform certain types of treatment. This is the same legal process that occurs when standing orders are used to initiate specific types of treatment by the prehospital provider.
The limited-treatment order may have several options, which are state-specific. Typically it states that chest compressions and artificial ventilation will not be used in emergency medical treatment. The order puts this in a format that is easily recognized by the emergency provider. It may stop an individual from undergoing intubation, the use of certain medications for cardiac resuscitation, or the use of electrical shocks for treatment. This plan often has check boxes that specify to EMS and other providers what resuscitation measures should not be used, but may allow measures for comfort, such as fracture care, control of external bleeding, application of oxygen and transport to the hospital in a position of comfort.
There are many ongoing issues related to the near-death patient. We will see a rapid evolution of events over the next several years related to hospice and other end-of-life care, particularly with concerns about healthcare cost efficiency. Present laws are an important first step in guidance for end-of-life events for emergency personnel. Specifics related to matters of death, near-death and use of limited-treatment orders should be discussed with the EMS department's legal and medical advisors.
James J. Augustine, MD, FACEP, is an emergency physician from Washington, DC. He is the director of clinical operations at EMP Management in Canton, OH, and serves as assistant fire chief and medical director for Washington, DC, Fire and EMS. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH, and a member of EMS Magazine's editorial advisory board. Contact him at firstname.lastname@example.org.
A 90-year-old female with altered level of consciousness and failing respiratory status.
Airway: Intact and uncompromised.
Breathing: In mild distress in a supine position.
Circulation: Patient has pale skin, delayed capillary refill, and is cool to the touch. Neck veins distended, edema in the lower extremities.
Disability: Patient is not verbal, responds minimally to verbal stimuli, and can move all four extremities, but not to command. No verbal attempts.
Exposure of Other Major Problems: Trauma to right wrist from a fall out of bed; no other injury. Patient and family do not want resuscitation.
Medications: Lasix, Coumadin, morphine, Keflex and Valium.
Past Medical History: Short history of lung cancer, with extensive metastases. Congestive heart failure, prior heart disease and multiple surgeries.
Last Intake: No food or intake for several days.
Event: Patient fell out of bed and was thought to have a broken arm. Has extensive history and a terminal illness, with appropriate documents related to a limited-treatment order.
Customer Service Opportunity: Communication with the family of a patient who is near the end of life results in significant improvements in care. The family is often uncomfortable with decisions about activating EMS when the patient is near death, and may be uncertain if they have the right documentation to guide care. Some situations can be resolved by phone communication with the patient's primary physician or the hospice agency involved with their care.
Learning Point: Acute injury in a patient with a terminal illness, who received appropriate care for the injury. End-of-life limited-treatment orders guide care for many of these patients.