No DNR Required: Why it should be our call to stop or start CPR
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 that 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 still and quiet and promptly lost her whole mind. She herself suffers from the beginnings of dementia and forgot that he was on hospice, so she called 911. Since she was confused, she didn’t know where his paperwork was so the BLS agency that arrived began efforts for resuscitation. This skeleton of a man, wasted and withered from the ravaging of his disease and its treatment, was dragged from his death bed 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.
Each of the people on that BLS crew are career providers. This is not the first time they’ve seen a dead body, nor did they have any illusions that their efforts will miraculously return this patient 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 its 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, who we know is not viable, who 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 as an EMT, I came across this 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 had 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 in to a house where the worst has happened and you’re already behind the 8 ball is not a Sunday stroll. We know this. Patient’s 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 have 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 they 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 efforts? 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… What if I could ask all uniforms to leave the small living room, remove the chaos and start to help the family face facts? What if I could sit everyone down, let them pray and grieve as I told them that 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 needed. I could play a different part in the death of a patient, the advocate instead of the resusitationist doomed to fail.
What if I had the choice to provide this kind of violent intervention to those who would most benefit from it instead of just a blanket approach to death. A clinically primitive mindset; 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, this kind of case I feel like its 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 are starting to raise the standards for entry level that shouldn’t be a barricade. Does that mean more interaction between our doctors and our field staff? Yes, because that kind of trust must be earned. That onus also lays at the physician’s feet. Have we met? No probably not, so how can you trust my judgement? I call you and ask to paralyze someone to shove plastic in their airway and basically buy them days to weeks in your care and THAT you’re ok with sight unseen? Why? Why do you trust me with procedures but not the ability to say that a clearly dead person is all the way freaking dead? Don’t site that people have made mistakes like that before, the same could be said about all of medicine. Tubes go wrong, IVs get pulled, doses get screwed up at 3am. Consider my actual position in the room and my experience in the field. Papers waived in front of me, family begging me to stop, and barring the lack of those things a cold and clearly dead human and a grieving; that’s something we have to talk about?! Where’s the protocol? We thrive on algorithm, why supply something along the lines of a check list to meet extra dead criteria? If this, then that. Basic concept in assessment performance. Spare the phone call and allow your field clinicians the ability stare at a watch over the very dead and read out the time.
Maybe its not a matter of “why don’t you trust me” and more of a “Here is your criteria, we share liability now” kind of solution. Place the responsibility of pronouncement on the field provider as equally as it lays at the physician’s feet.
Anyone who has worked professionally in the EMS field knows that sometimes policies can be a little ridiculous. Algorithms are kind of our life’s blood, but they’re fluid and anyone who has taken a alphabet soup recert knows that things ebb and flow. Policy, however, is based on the “what if they sue” factor. That’s not always for us to understand, we grunts in the streets just have to 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 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 that are outside of policy that require us to apply compassion. Then what? If only we were providers who could think critically, outside the box.