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Patient Care

No DNR Required

Have you ever come away from a shift seeing red? Sure, sometimes things go wrong, you get a little emotional. I’m not talking about that. I’m talking about questioning what it is you’re doing here besides pushing paper.

I had a call that turned out to be a code. The patient had suffered through several kinds of cancer to finally arrive at the peace he deserved, slipping silently away as his wife went to the kitchen to cook dinner. When she came to see if he wanted food, she found him cold and quiet and promptly lost her whole mind. She herself suffers from the beginnings of dementia and forgot he was on hospice, so she called 9-1-1. Since she was confused, she didn’t know where his paperwork was, and so the BLS crew that arrived began resuscitation efforts. This skeleton of a man, wasted and withered from his disease and its treatment, was dragged from his deathbed and laid out on his bedroom floor while strangers pounded on his frail chest.

It’s not what they wanted. It’s not what he wanted either. These experienced providers were obligated to lay hands until I walked in the door as the assigned medic unit, and even then I had to attach a monitor to confirm what everyone in the room already knew.

All the people on that BLS crew were career providers. This was not the first time they’d seen a dead body, nor did they have any illusions that their efforts would miraculously return him to this plane. Is there any reason why these providers had to go against the wishes of the dead and his family simply for the lack of a document? They carry the same CPR card in their wallets as I do, they readily use the brains between their ears, so why are we made to perform futile efforts on a patient who didn’t want the help to begin with?

Our hands are tied, and it’s infuriating.

How are we supposed to best serve a community if we are not allowed to use our clinical judgement? The days of technicians in this field are over. We are trained professionals who should be thinking of the whole picture and not just the presence or lack of paperwork. A patient who is not viable, whom we know is not viable, whom we work anyway, damages us mentally and challenges us physically. It puts us at risk for injury. It stresses the mind and the soul.

When I first started out, I came across a similar situation. I performed compressions while staff frantically searched for the orders that would make me stop and waited for the higher medical to stay my hand. The fact that I’d dishonored someone’s last wish haunted me for days. Compressing that patient’s chest felt wrong, but I had no power to do otherwise.

We are better trained than the cautionary “what if he’s not all the way dead?” code!

Walking into a house where the worst has happened and you’re already behind the eight ball is not a Sunday stroll. We know this. Patients’ families don’t understand what you’re doing. Your presence gives them false hope. They have strange reactions, ranging from violent to crushed, when you tell them the efforts didn’t work. You learn to defend the actions they called you for without knowing better. You’re supposed to be savior and anchor, and making you act takes away your clinical prowess and puts you in a villainous position.

You didn’t try hard enough. You didn’t get there fast enough. Please don’t stop, he can’t be dead. What do you mean there’s nothing else you can do? Tell me you don’t hear that voice in your head.

What if we were trusted to make the call not to start? What if I walked into that house, heard the word hospice and saw his ravaged body, listened to the confused wife who panicked at the sight of a dead husband, and what if I could ask all uniforms to leave the room, remove the chaos, and start to help the family face facts? What if I could sit everyone down and let them pray and grieve as I told them I was not there to resuscitate their husband and father but to honor his wishes. I could help them call the hospice nurse, make sure his wife was calmed, help his daughter gather paperwork, and provide the police with the information they need.

What if I had the choice to provide this kind of intervention to those who would most benefit from it, instead of just a blanket approach to death? It’s a clinically primitive mind-set: no heartbeat bad, CPR good, liability avoided.

I’ve written about how we aren’t approaching death well before. I’m not the first one to say things like this, and I won’t be the last. Education and culture change aside, with this kind of case, I feel like it’s also a matter of trust in the clinical judgement of the providers in the field. Does that mean a little more training or continuing ed? Yes. In an age where we’re starting to raise the standards for entry level, that shouldn’t be a barricade. Does that mean more interaction between our doctors and field staff? Yes, because that kind of trust must be earned. There is a difference between demanding respect for our clinical abilities and commanding it, and in the interest of providing actual service and not curtailing to idle policy, we must learn the difference.

Anyone who has worked in the EMS field knows sometimes policies can be a little ridiculous. There aren’t always reasons we grunts in the streets understand, we just follow them and move on. Show up in uniform, do your check sheets, make the stretcher, and don’t piss off the nurses. Simple, just obey the rules. Except…not so simple. Sometimes the call volume is high, and you don’t check the truck until halfway through a shift. Sometimes you throw a couple of sheets on the stretcher and run out the door to pee or eat or get the board cleared. Sometimes the patient who swore she wasn’t nauseous throws up all over your pants. Things happen outside of policy that require us to apply compassion. Then what? If only we were providers who could think critically, outside the box, and use our judgement.

Oh—wait.

Anna Ryan is an EMS educator and blogger from New Jersey. She is a regular contributor to The Overrun podcast.

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