By Steven P. Velasquez - NREMTP, MICP
April 4, 2010
A team of paramedics are dispatched to a nursing home for a person with respiratory distress. Upon arrival, they find a BLS crew moving the patient over to their stretcher. The patient is barely breathing on their own and is showing signs of poor perfusion as evidenced by their mottled, diaphoretic skin, their rapid pulse and extremely labored breathing where they employ all their accessory muscles to breathe.
The paramedics prepare their advanced airway equipment and instruct the EMT's to begin bag-mask ventilations with supplementary 02. The patient's chart has yet to make its way into the room, so nothing is known about the patient or their history. A nurse walks in and states "this patient is here for hospice and has a DNR." After a deep collective sigh, the paramedic uncrosses their eyes and withholds the next logical question ("then why are we here lady?"). The nurse vanishes from the room and the paramedics are left with this critically ill patient with an unstable airway (pooling secretions in the pharynx), severe dyspnea / respiratory failure, sepsis (106 degree fever) and his / her life hanging in their hands.
The nurse returns with all the paperwork except (drum roll please) the DNR (Do Not Resuscitate) form. They can't seem to find it and subsequently, if they don't present it, the paramedic's can't honor it. So, this patient who's body is riddled with cancer and has other co-morbidity's is intubated, suctioned, ventilated and a detailed secondary exam is performed including an ECG (electrocardiogram) which now reveals a life-threatening arrhythmia -- Ventricular Tachycardia (with pulses). The patient has a blood pressure of 160/110, a heart rate in the 180's and is being ventilated with oxygen. The DNR form finally arrives and states the exact instances when it is to be observed. It states that if either the breathing or heart beat stop, no extraordinary measures are to be performed. Currently, NONE of these factors are present, so the form is equally as null as when it wasn't there. The paramedics proceed.
IV access is established and large amounts of Normal Saline are infused to combat the fluid loss (hypovolemia) associated with the patient's wide-spread infection (sepsis). An anti-arrhythmic (Amiodorone) is drawn up and infused slowly. After only a few minutes, the v-tach is resolved and the patient's ECG returns to a normal sinus rhythm (the rhythm we all want!). Unfortunately, with the correction of the patients' lethal condition, their natural compensatory mechanisms begin to fail and their blood pressure falls to 50/30 (not enough to sustain human life).
The paramedics call their telemetry physician and receive orders on how to proceed including accessing the patient's port (device beneath the skin for IV access) and large volume hydration but no more medications. The patient is transported to a local hospital where the EMS crew is "greeted" by the charge nurse. As they roll the critically-ill patient down the hallway she yells:
"Is this the DNR that you intubated?" The paramedic tries to demonstrate diplomacy while correcting the inappropriate nurse and counters: "No, this is the patient, who is critical and needs your care, is intubated and has a DNR." She rolls her eyes, sucks her teeth and proceeds to bad-mouth the paramedics in front of the mini-chorus of young ER nurses (who all look barely old enough to be there). "Then why did you intubate him?" she sarcastically asks. "We're just going to extubate him and send him back to the nursing home -- like the family wanted." All of this is transpiring over the patient and in plain view of the entire emergency room, the other patients and their families looking on. The patient is moved over to the hospital bed and care is transferred to the staff. Finally, the patient's family arrives and initially inquires with the nurse why the patient is intubated. The nurse rolls her eyes in my direction and says "go ask him."
By this point anyone reading this is probably ready to shoot the charge nurse right? Trust me, I was too. She embarrassed me personally (more than once). She embarrassed herself and really showed gross apathy and disregard for her profession as a whole. I collected myself and consulted with some trusted RN's and believe I have discovered the disconnect.
The nurses have a very different understanding of DNR's, according to their education, than EMS providers. The one's I've spoken to have stated that they were unaware of how EMS providers have very specific instructions (inclusions / exclusions, parameters) to follow pertaining to DNR forms. Some are written where we can give fluids but no medications, provide oxygen but no intubation, jump on one leg rubbing our belly with our left hand and... you get the idea. Their (the nurses) interpretation is something akin to a "Let Me Die" form. This fictional form would be a blanket form that is A: easily understood and B: universally applicable. Once signed, it wouldn't matter what the hell was wrong with the patient, "Let Me Die." If my heart or breathing stops, "Let Me Die." If my blood pressure or heart rate are too fast or slow, "Let Me Die." If I cough, have a fever, vomit, am shot, catch fire or fall off a building -- "Let Me Die." This would make everyone's life much easier with the very sticky topic of preserving human life when there is no promise of quality of life.
In summary, this could all have been avoided if the nursing home had followed the instructions regarding hospice patients. The patients are in their care for comfort and palliative care only. They are there to prepare for death. By being in a hospice program, they are fully aware that the end is near and their family's wishes are that they not be intervened with. Yet, this call happens all to often, trapping EMS providers right in the middle of these conundrums.
The nurse should have accepted the patient, taken over his / her care and interviewed the paramedics as allies and professionals in health care. Any questions she may have had could be easily, courteously and professionally answered but she chose her way.
I'll be introducing proposed legislation to my congressman to abolish the complex DNR forms and all their rules and change them to the new streamlined "Let Me Die" form or better yet, a wrist band, perhaps black in color indicating to providers "Let Me Die." No more lost forms, no more questions whether to proceed or stop just Let Me Die.