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CASE OF THE MONTH - MARCH 2019

Case Presentation

Paramedics respond to a 94 year old female living at a nursing care facility.  She has a history of dementia, COPD, CHF, and HTN.   Facility staff called EMS because the patient was noted to have increased work of breathing.  The patient typically speaks and is oriented to person and place, but today she is non-verbal and unable to provide history.  She appears to be in moderate distress with labored breathing and tachypnea.  On further examination, she is tachycardic with occasional wheezing and decreased tidal volume.  There is no JVD and no rales are appreciated.  Her skin is pale and capillary refill is > 2 seconds.  Her vital signs are HR 125, BP 72/48, RR 32, O2Sat 81% on 2L NC (baseline O2 requirement).  The facility staff share the paperwork below:

Case study

 

 

 

1.

What information can you derive from the paperwork provided?

The patient has a valid Physician Orders for Life-Sustaining Treatment (POLST) form that is signed and dated by her physician and her son who is her legally recognized decision maker (Section D). 

The form outlines interventions that can be administered or withheld in accordance with the patient’s/patient’s decision maker’s goals for end-of-life care. 

Section A addresses interventions for a patient that is found with no pulse and not breathing

The options are Attempt Resuscitation/CPR or Do Not Attempt Resuscitation/DNR.  If the patient is not in cardiopulmonary arrest, orders in Sections B and C should be followed.

The patient in this case should not be resuscitated if found pulseless and not breathing since “Do Not Attempt Resusctiation/DNR” is selected.

Section B addresses medical interventions that can be initiated in accordance with patient/decision-maker wishes and physician orders when the patient is found with a pulse and/or is breathing

The options are “Full Treatment”(intended to prolong life by all medically effective means), “Selective Treatment” (intended to treat medical conditions while avoiding burdensome measures), and “Comfort-Focused Treatment” (intended to maximize patient comfort).  If “Attempt Resuscitation/CPR” is selected in Section A, “Full Treatment” should be selected in Section B.   For patients that select “Do Not Attempt Resuscitation/DNR” in Section A, any box may be checked in Section B for care if they are with a pulse and/or breathing. 

The patient in this case is “Comfort-Focused Treatment”.  Goals for her would be to relieve pain and suffering by using medications, oxygen, suctioning, and manual treatment of airway obstruction.  Hospital transfer should only occur if comfort needs can not be met at her current location.

Section C addresses artificially administered nutrition options and is not typically relevant to EMS providers. 

 

2.

What are the next steps in the management of this patient?

This patient is in respiratory distress with poor perfusion.  After administering 100% oxygen by non-rebreather mask, she remains hypoxic (SpO2 89%).  Given her persistent hypoxia despite 100% oxygen therapy, a provider impression of Respiratory Arrest/Failure (RARF) is appropriate and comfort care can be initiated in accordance with TP-1237 and the POLST.  If the patient’s decision maker and/or physician can be contacted to determine comfort care goals, this information would be useful in clarifying the extent of comfort measures to be pursued.  This information can also be used to determine if those measures can be met in her current location or if the patient should be transported to the hospital.

3.

Case Update

Paramedics continue high-flow oxygen for the patient.  They are able to contact the patient’s physician using the contact information on the POLST form.  The physician confirms that only oxygen and suctioning are consistent with comfort goals.  The patient does not want any IVs, medications, or other medical treatment.  The nursing facility has also contacted the patient’s son (legal decision-maker) who agrees and is firm that the patient does not want to be transported to the hospital.  Paramedics confirm with facility staff that oxygen and suctioning as comfort measures can be continued by facility nursing staff. 

Despite on-going comfort meaures, the patient’s condition worsens.  She becomes increasingly tachypneic and hypoxic.  In accordance with Ref. No. 815, no further interventions are indicated as per the patient’s and decision-maker’s wishes.  The patient appears to be near end-of-life.  Paramedics contact the Base since she is in respiratory failure in accordance with TP-1237 and to determine if any other direction regarding transport or treatment intervention would be recommended.  The Base agrees that no further management is indicated and comfort measures are continued by the facility staff.  If she goes into cardiopulmonary arrest, no resuscitation should be performed.

4.

Learning Points

The rights of patients to refuse unwanted medical intervention is supported by California statute.  In end-of-life clinical situations, the goals of care in accordance with a valid DNR order and desired treatment goals should be determined.  For patients evaluated in a licensed health care facility, valid DNR orders may include:

  • A written document in the medical record with the patient’s name and the statement “Do Not Resuscitate”, “No Code”, or “No CPR” that is signed and dated by a physician
  • A verbal order given by the patient’s physician who is physically present at the scene and confirms DNR in writing in the patient’s medical record,
  •  POLST with DNR checked
  • Advanced Health Care Directive (AHCD) with instructions to withhold/discontinue resuscitation.

If at a location outside of a licensed health care facility, valid DNR Orders may include:

  • Fully executed EMSA/CMA Prehospital Do Not Resuscitate Form
  • DNR Medallion
  • POLST with DNR checked
  • Advanced Health Care Directive (AHCD) with instructions to withhold/discontinue resuscitation.

Figure 1.  In California, Medic Alert and Caring Advocates are the two medallion providers approved to issue DNR medallions. 

Patients with a DNR may desire selected medical interventions to include IV fluids, IV antibiotics, intubation, CPAP, oxygen or suctioning if they are breathing and/or with a pulse.  This may be documented on a POLST form, AHCD or determined in discussion with the patient or the patient’s legal decision-maker.  Evaluation of treatment goals will determine if the patient is best served by transporting to the hospital.  In some cases, transport may not be indicated if  they are against patient wishes and goals of care.  For any cases involving unusual circumstances or questions on appropriate care in accordance with policy, EMS providers can always contact the Base for guidance.

 

5.

Case Conclusion

The patient’s son arrives and thanks paramedics for caring for his mother.  He confirms that no further care is desired.  Paramedics depart.  A few hours after her son’s arrival, the patient becomes apneic and pulseless with a bradycardic PEA rhythm.  Within a few minutes, the patient’s rhythm changes to asystole.  She has no spontaneous breathing, no pulse, and no neurologic reflexes.  She is pronounced dead at the facility by her physician in the company of her son.