You are working the overnight shift for All-City EMS when the call comes over the radio: "Medic 4, respond to 422 Mount Prospect Ave., single-family home, sick, semi-responsive male, time out 22:26 hours." You arrive to find a 55-year-old male in no apparent acute distress. He has stomach cancer. Over the last 12 hours, the patient has not been able to keep down food or water and has had several bouts of diarrhea. He is now listless, but is able to answer all your questions. The patient's wife states that she called hospice 30 minutes ago, but no one called back, so she dialed 9-1-1. She doesn't want the patient to be transported until hospice gets there to evaluate his condition. As your partner completes his patient assessment, you explain to the patient's wife that you are an emergency ambulance and would be more than happy to either transport to a stabilizing facility or have her sign an RMA, but you can't just stand there and wait. She's not sure what to do. You aren't sure what to do either--take the patient to the hospital, or call for a supervisor?
Chances are, with the increase in patients with serious chronic and terminal illnesses being managed at home, most EMS providers will experience situations similar to this over the course of their career. So what do you do? Should EMS respond to these calls? Should you take the patient to a hospital, or wait for hospice personnel? What exactly is the role of hospice, and how does it impact your care decisions? Beyond Refusals of Medical Assistance (RMAs) and Do Not Resuscitate (DNRs) orders, most EMT and paramedic programs don't discuss hospice and terminal illness/condition issues enough to help EMS providers become knowledgeable and act appropriately when faced with these patients.
Understanding Palliative Care
The Merck Manual of Diagnosis and Therapy identifies palliative care as "noncurative care and support services for patients with terminal illnesses (life expectancy less than six months) and their families." Palliative care customarily includes traditional and alternative-medicine approaches to pain management, relief of nausea and vomiting, maintaining nutritional intake, emotional support for radiation and chemical therapies, and the hospice concept. The optimal goal of palliative care is to provide comfort to the patient prior to death, whether or not the treatment actually prolongs life expectancy.
Medical associations have made limited attempts to address the uniqueness of the palliative care situation in the prehospital arena.
The American Medical Association's policy statement regarding the treatment of cancer patients, though not specific to prehospital interventions, expresses the belief that care does not end when cure is not possible: "[The Association] recognizes the need to ensure the highest standards of symptomatic, rehabilitative and supportive care for patients with both cured and advanced cancer; supports clinical research in evaluation of rehabilitative and palliative care procedures for the cancer patient; encourages the implementation of continuing education of the practicing American physician regarding the most effective methodology for meeting the symptomatic, rehabilitative, supportive, and other human needs."
The American College of Emergency Physicians, in a paper titled Do Not Attempt Resuscitation Orders in the Out-of-Hospital Setting, states, "In both out-of-hospital and hospital settings, current resuscitation techniques generally fail in patients with comorbid illness, terminal cancer, and other irreversible disease states when they suffer a cardiopulmonary arrest."