Don't Care for Mama

What limited-treatment orders like 'do not resuscitate' orders, living wills and powers of attorney mean for EMS crews

      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.

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