New Protocol Lets Washington EMTs Forgo Resuscitation

"Compelling Reasons" | A new emergency-response protocol is designed to spare families the nightmare of an "inappropriate" resuscitation.

Mary Sundborg was a spirited woman of 100½ who had long endured advanced colon cancer and two strokes. And she knew how she wanted to die: at home, peacefully, with dignity.

So with the help of her eldest son, she signed an official order specifically directing emergency responders not to attempt CPR.

Then came Jan. 3, the day Sundborg stopped breathing. Her nurse, who wasn't sure at first what was happening, called 911. When emergency medical technicians (EMTs) from the Fire Department arrived at her Magnolia home, they pulled her out of bed, attached their equipment and began pushing on her chest.

"Put her back in bed!" the nurse yelled. Sundborg didn't want to be resuscitated, she told them, waving the "No-CPR" order. One of the emergency workers told her the order had expired, and kept going.

But Sundborg was dead.

"It was terrible, absolutely terrible," said her nurse, Bonnie England. "It felt very disrespectful. It was just so wrong."

And it was far from an isolated case. Emergency medical responders, long trained that a 911 call is a request for resuscitation, have routinely ignored family members who ask that CPR not be given to their loved ones who are dying of terminal illnesses.

This year, that is changing in most King County jurisdictions, thanks largely to years of effort by two South King County paramedics who saw the current system as an affront to patients' wishes for peaceful death.

For the first time, EMTs the first responders to 911 calls are being given the latitude to forgo resuscitation when they judge it to be "futile, inappropriate and inhumane" even when there is no official paperwork.

The protocol, dubbed "Compelling Reasons," is the first of its kind in the country. A study of a pilot program in South King County fire districts, published in the latest edition of Annals of Internal Medicine, found that all but a few EMTs felt comfortable letting their patients die in peace.

"Sometimes, the right thing to do is to not do a resuscitation," said Dr. Mickey Eisenberg, medical director of King County Emergency Medical Services. "The reality is you have to accept the concepts of patient autonomy and futility."

Not everyone is accepting the changes wholeheartedly.

Bellevue Fire Department is still studying the protocol. And while the Seattle Fire Department, the agency that gave CPR to Sundborg, has officially signed on to the new training, "our mind-set is to save a life," said spokeswoman Lt. Sue Stangl.

"Now, all of a sudden, we're asked to question that judgment."

"It was wrong"

When someone calls 911, a swift-moving system clicks into place as EMTs are dispatched.

Until now, protocols have left EMTs with little discretion. They weren't allowed to accept family members' word that a patient had a fatal disease and didn't want CPR. Even properly signed "Do Not Resuscitate" (DNR) orders were usually ignored when EMTs first arrived.

"We wouldn't even talk to the family member," said Tom Curtis, a Renton EMT. "We'd rush in, rush right past them, throw down our equipment and get to work. We're really good at pushing people out of the way and just taking over."

That response is "deeply embedded in the system," Eisenberg says. "You don't want people to get to the scene and start deliberating, because seconds make a difference."

Once under way, a resuscitation effort could be halted by paramedics, more highly trained emergency workers who are summoned on more serious calls, but only after consulting with doctors. And by then, some families complained bitterly, their loved one's wishes had been violated.

It was one of those cases, in the early 1990s, that left King County Medic One paramedic Sylvia Feder determined to change the system.