Posted by: medicblog999 | August 5, 2009

Another moral dilemma

sbAngelDevilI have just had an email from Matt tonight, who describes a job he was at recently and asks my opinion on what happened. It was one of those jobs that left him wondering if the decisions made were the correct ones. I will reproduce the email below (with his permission) and open it up to you guys for your opinions too. It should provide an interesting discussion for those of us in the profession, and for those readers who aren’t medically orientated, hopefully it will give you an insight into some of the tough decisions we have to make.

Over to Matt:

First off I like to say it was not my patient but my partners as we alternate each call. We responded to a local Nursing home for reports of an elderly male who had aspirated some vomitus. We arrive on scene its about 11PM. We are met by the patients nurse in the hallway who states that he has been admitted short term for a bout of pneumonia. He has been feeling a little unwell and just prior to our arrival he vomited at the same time taking a deep breath and he had aspirated a significant amount of vomit. The nurse had informed us that she had tried to suction using a yankhauer as best she could but that he was still in significant distress. As we enter the room we find an elderly male in bed with the head of the bed upright. You could hear from the end of the hallway that his lungs were full of fluid. He was in pretty bad shape. He was cool and pale. His O2 saturations were in the mid to high 60s on a nasal cannula which improved to about 69-70% with a non rebreather, he is breathing about 24 times a minute and his mental status is pretty much in the toilet from hypoxia i’ll give him about a GCS 5. This poor gentlemen needs some agressive treatment and here we are to help. Now here comes the dilemma. He has a Do Not Resucitate order for an unrelated medical condition and as soon as it is produced everyone seems reluctant for aggressive treatment. Now my train of thought is a DNR is strictly in place for when a patient is in cardiac or respiratory arrest. Now some may think that intubating is a resusatative measure which it is when in an arrest type situation but for this particular case my thought was to prevent further aspiration and a means to try and suction some of the vomit that was in there. However my partner disagreed on the intubation route and did not want to perform that intervention. Now however he did mention using CPAP which I was unsure about due to the fact that it was not edema in the lungs it was vomit and our main goal was to get the vomit out not try to push it back into the circulatory system. Now I was just the driver in that situation so I left it in my partners hands to do the right thing. I then proceded to drive rather quickly to the hospital which was about 8 mins away. Unfortunately all my partner decided on was vascular access and continuation of his non-rebreather along with the standard ECG etc. At the hospital I thought the doctor would then do the right thing and maybe intubate but again the DNR surfaced and he said ” Well I wont be intubating him” and I believe he ordered BiPAP and NG suctioning and at that point we completed our handover and left. I never did follow up with this mans outcome but im sure the outcome was not good. Does anybody else think that the intubation/suctioning route was the way to go. We do have RSI capabilities and I feel that this would have been in the best interests of the patient. Would there be anything you would have done differently I would love some feedback.

I suppose I should put my oar in the water first…

In all honesty, I think I would have done the same as Matts partner (possibly even without the IV). In my eyes a DNR is a DNR, and it is applicable in ‘pre-terminal’ events. As I understand it, the patient does not have to be in full cardiac arrest for the DNR to stand. We were not present when the discussions and decisions were made and therefore we were not to know the ins and outs of a potential living will, which may have been made before the formal DNR.

Matt states that the cause of the call was separate from the condition causing the DNR, however, the patient in all likeliness had a life shortening illness which was coming to its natural conclusion, and any ‘extraoridnary’ interventions may well have still been against the wishes of the patient.

It can be really,really hard to stand back and do nothing, but in my humble opinion, I think it was the right (and safest) decision. That doesn’t make it any easier to sleep at night though!

I hope that helps Matt, and I hope my wonderful friends out in the great blogosphere can offer their opinions too. Over to you guys!!

Advertisements

Responses

  1. I wrote a post on my opinions on DNR orders some time ago. In it, I stated that a DNR order is just that, a “Do Not Resuscitate” order. It is NOT, in my personal or professional opinion, a DNT or “Do Not Treat” order. Letting someone die by drowning in their own vomitus is just, well… inhumane.

    With that said, I don’t think that intubation would be in the patient’s best interest either and I probably would have gone for the CPAP here. I also question the “nursing home nurse’s” assessment of the situation and I question that this wasn’t actually an exacerbation of CHF instead of a case of aspirated vomitus. More explanation of the patient’s presentation is neccesary to make that determination.

    For my part? I would aggressively maintain that airway. Could he have aspirated a ton of vomitus? Maybe… but I’ve never seen someone that couldn’t protect their airway until they were severely obtunded. I’ve never had someone who I could “hear from the hallway” that had simply aspirated.

    Besides, is it physically possible for a conscious patient to inhale *and* vomit at the same time? Isn’t there an involuntary reflex that closes the epiglottis?

    More info is neccessary, but with the information presented I would have assessed the patient further (never rely on a NH assessment) and probably went towards CPAP. I may have intubated if I had to. If it were me and I had a signed DNR order that I had signed myself… would I want to drown in my own vomit while people watched? or would I want intubated for a while? EMS people have these sorts of decisions in their laps a lot. They’re hard

  2. By what the nurse had stated on scene she was in the room when he had vomited. I think i may have heard some noodle soup was involved but im not entirely sure why they were feeding him at 11PM. You could hear him ” gurgling ” from the door with all the classics signs of pulmonary edema but with vomit/noodle soup instead. Also CK would CPAP be viable in this case if it were vomit in there or would that make it worse? Thats one im completey unsure of.

  3. In the moral dilemma (and not the legal, that’s another question), for me, I think the difference would be “is the patient dying of his illness, or something completely different?” If it’s his illness, or related, then absolutely DNR. But if not? Is it right to not save someone from, let’s say a possible fatal cut in the head, because you know he has terminal cancer and a DNR-order? What would his family feel when they found out we watched him bleed to death?

    This patient may be dying, but surely not from noodle soup?

    As for intubating, cpap or iv access, I believe that you either treat the patient, or you don’t. If you’re going to try and treat him, you do what you can. If not, do nothing at all, and try and keep him company as he struggles. At least you won’t be prolonging his death by treating him a little, but not enough.

    But it’s a real dilemma, and I don’t envy the crew. I think you guys did well, all things considered 🙂

  4. Very difficult situation. Do nothing and you’re an uncaring pig…..do too much and you’re possibly over-riding the DNR.
    Some aggressive suctioning (through an ET tube may have helped) but with a GCS of 5 who’s to say that the pt. was in any way aware of their condition or “perceived” distress at that point anyway ?
    Maybe the only discomfort eased would be our own, knowing that we did all we could and easing our conscience

  5. An old instructor of mine used to tell us that there were thousands of “What should I do if…?” questions that we could throw at him, but each question had the same answer. The answer is always, he said, “the best you can.”

    I think that explanation may oversimplify things, but I like to keep it in mind when I begin to replay scenes in my head, pose hypotheticals, or second-guess my actions.

  6. The DNR states the patient’s wishes. That does not stop us from mechanical interventions to maintain level of life. The suctioning of the seated patient is hilarious and everyone slowing down when seeing the DNR is frightening.

    What would Happy do?

    The Inverted Trendellenburg of course. http://yourhappymedic.blogspot.com/2009/04/new-airway-technique.html

    Get him on the ground, turn him over and let gravity clear your airway. Did it twice in July alone with great results. CPAP, in my opinion, based on the reported aspiration is a bad call. We’ll get bitchin’ sats to write down but the chunks will be forced deep and dry out making removal later near impossible. That is taking the staff’s word for what happened, and that I’m seeing a lot of aspirations as of late.

    If it is CHF, the CPAP will work, if not…

    My main concern on this job was your partner starting an IV, but not considering intubation. There is a disconnect there on the term “invasive” I think.

    I would keep my interventions simple, but effective and avoid intubation if I can control that airway with a BVM when he is supine.

    Tough call, I’d be curious to hear Epi Junky chime in on this right before starting P School, then again after and see if her interventions are different. Epi? You out there?

  7. Mark, thanks for the email invite to comment here, and Matt, thanks for having the courage to post this experience. We can’t move our profession forward without posting these calls, our questions and discussing them.

    For the readers outside of the United States, you should be aware that each State sets its own laws and regulations regarding DNR orders; there is no nationwide standard. Each State’s law may be different.

    First a bit of a disclaimer: I am educated in United States common law and most specifically educated in the law of South Carolina, the State of my bar admission. I am also registered as a NREMT-P in South Carolina so I am most familiar with South Carolina’s laws on DNR orders.

    My thoughts here will focus first on the law within the jurisdiction I practice law and ride an ALS truck. I will then discuss my thoughts as to the call posted by Matt, and will end with a sampling of DNR regulations from other States for comparison.

    Here in South Carolina we have the Emergency Medical Services Do Not Resuscitate Order Act. To establish a DNR order in South Carolina, the patient must: (1) have a terminal condition; and (2) the terminal condition must have been diagnosed by a health care provider and the health care provider’s record establishes the time, date, and medical condition which gives rise to the diagnosis of a terminal condition. Thus, it is a pre-requisite to have a physician established terminal condition.

    When EMS personnel are presented with a valid DNR order EMS personnel must not use any resuscitative treatment. EMS personnel must provide that degree of palliative care called for under the circumstances which exist at the time treatment is rendered.

    Okay, that is some great lawyer-speak, but what constitutes the “resuscitative treatment” we can’t give, and what does “that degree of palliative care called for under the circumstances which exist at the time treatment is rendered” mean for those of us in the street?

    For that guidance we must consult South Carolina Department of Health and Environmental Control Regulation 61-7, Sections 1406 and 1407. In the event that the patient has a valid DNR order, the following procedures shall be withheld or withdrawn: (1) CPR; (2) Endotracheal intubation and other advanced airway management; (3) Artificial ventilation; (4) Defibrillation; (5) Cardiac resuscitation medication; and (6) Cardiac diagnostic monitoring. These 6 items are defined as prohibitive resuscitative treatment in the presence of a valid DNR order.

    The following treatments may be provided as appropriate to patients who have executed a valid
    DNR order: (1) Suction; (2) Oxygen; (3) Pain medication; (4) Non-cardiac resuscitation medication; (5) Assistance in the maintenance of an open airway as long as such assistance does not include intubation or advanced airway management; (6) Control of bleeding; and (7) Comfort care. These 7 items are defined as the permissible palliative measures that can be given in the presence of a valid DNR order.

    Okay, so that is what we can do and can’t do in the presence of a valid DNR order. But wait, there is more. When presented with a valid DNR order, you must honor it, regardless of the circumstances. If you can’t or won’t honor it, then you must immediately transfer patient care to another EMS provider or other healthcare provider who will honor it.

    That is the law in the State I work.

    Let’s restate Matt’s patient presentation: Elderly male, lungs full of fluid, SpO2 mid to high 60s on a nasal cannula, improved to about 69-70% with a non rebreather, respirations about 24, mental status , about a GCS 5. Nursing home staff states aspiration of vomitus, suction attempted with no relief. Valid DNR presented to EMS on arrival.

    If I was presented with the above in my jurisdiction, right off the bat there are several things that I cannot do for this patient in the presence of the valid DNR order. I cannot drop an ET tube, King Airway or LMA. I cannot use a BVM to artificially ventilate. I cannot attach my LifePak 12 for cardiac monitoring.

    My patient revoked my ability to use these tools, and I will respect their decision, but I won’t just watch them circle the drain. There are things I can do that may really help this patient. First, I will do my own assessment, as I do not trust NH assessments. I can still suction, so I would try to clear the airway as best I can. Here, an OPA is a basic skill, so dropping an OPA to maintain an open airway would be permitted. I can administer oxygen via non-rebreather over the OPA. (A tougher question would be whether CPAP or BiPAP is considered artificial respiration. I’ll punt on that one for now.)

    I can also establish an IV and check a BGL. Who knows, maybe his blood glucose is 20 and an amp of D50 perks him up. I can…well, you get the idea. There are things we can do and should do to care for our patients.

    Matt, at least from what you wrote, I think your partner did the correct things in respecting the patients wishes. These are tough situations for us because we are used to doing all we can with all we got. But we must remember that our primary purpose is quality patient care, and sometimes that means respecting our patient’s wishes regarding the end of life.

    Matt, I wish you well and appreciate your posting this call.

    Other State DNR order regulations for comparison:

    State of California:
    http://www.emsa.ca.gov/pubs/docs/EMSA111DNRGuidelines.doc

    State of North Carolina:
    http://www.ncleg.net/EnactedLegislation/Statutes/PDF/BySection/Chapter_90/GS_90-21.17.pdf

    State of Texas: http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=25&pt=1&ch=157&rl=25

    Mark, thanks again for the invite to comment here. Keep up the good work on the blog, and stay safe out there.

    Pete.

  8. Thanks for all your comments. Happy the HIT LAST is the road I will be travelling on next time. As for the DNR in Florida is states the witholding of CPR, intubation and defibrillation in the event of cardiac or respiratory ARREST but I agree its a bit of a gray area so maybe im going to go work for McDonalds instead…..way easier. LOL.

  9. Pete,
    Thank you for your perspective. The fact that each state has different definitions of the same thing is silly, yet makes perfect sense at the same time.

    The definitions of artificial respiration are in such a gray area along with what is “invasive.”

    I had a great uproar when a fellow care giver told me that cardio version was non invasive. Yikes!

    Thanks again Pete and Matt for bringing this situation into the discussion. We can’t move forward until we’re all on the same page care wise.

  10. Hi, I am a new reader of this blog!
    I don’t work in the medical arena but I have seen family members deteriorate and can appreciate the value of DNRs. In my opinion I think it would be right not to intubate but to just try and make the patient more comfortable and let nature run its course (as harsh as that sounds). At the end of the day, you could sort the poor chap out on this occasion but whats to say he doesn’t suffer further episodes or other unrelated complications in the future? Somewhere along the line this patient or his family have decided enough is enough and I think it is important to respect that.

  11. As a non-medical-professional (yet!), I can only look at this from the patient’s perspective (for the second time on this blog, heh…)

    If I were to go through the process of getting a DNR, I can only assume it is because I am sick of living in pain and would like to go as peacefully as possible without incurring any extra cost – financial or emotional – on my family. I know those in the medical profession are often self-motivated to keep their patients alive no matter what, but that’s really not fair to the patient.

    I don’t know all these fun technical terms you guys are throwing out, but if I was in the patient’s shoes I would hope that the paramedics on scene would do their best to alleviate any pain, and that’s all. Presumably it is pretty terrifying and painful to have lungs full of vomit, but if that happened to me I’d like to be put at ease instead of having a crew of paramedics sticking tubes down my throat and prodding me in any other manner of ways.

    Of course, legally, you could be in a ton of trouble if the aspiration wasn’t related to the condition the patient has the DNR for… so I guess the most intelligent thing I can say here is thank God I’m not a nurse yet!

  12. @HappyMedic

    Thanks for asking me to respond. This is a tough one, although it’s a spot I’ve been in several times. It doesn’t get any easier with time.

    I’m in the US in the state of Ohio where I work as an EMT-B, so my intubation options are limited from the start. In the absence of legitimate DNR (I need to see the DNR paperwork or a bracelet with the state logo), I am able to intubate if the patient is pulseless and apneic.

    Operating as a Basic, here’s what I would have done (and have done in the past):

    A quick assessment, O2 by NRB, suctioning, put the patient in the recovery position, and haul butt towards the local ER. I have the option to use CPAP as well, but I can’t imagine what good it would have done if the patient truly aspirated.

    As a Medic (I’ve been through school once, for what it’s worth, washed out 11.5 months into the program due to a back injury), I can’t say that I would have done much more. Would I start an IV? If the patients BGL was tanked…

    It’s a brutal situation to be in a healthcare provider. It’s heartbreaking, but for myself, I just do what I can. That doesn’t include violating their DNR, which I believe intubating would do.

  13. […] Bride reference aside) but our topics are about death. This week we discuss a blog post on the Medic 999 Blog discussing a DNR Case, what would you have done? We also discuss EMS Official Comments on Mistaken […]


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Categories

%d bloggers like this: