Willed Death

You’ve been called to a residential care facility for an early-morning cardiac arrest. On arrival, a CNA guides you and an engine company down a hallway to a patient’s room. You encounter a woman in her eighties lying in one of two beds, the other of which is neatly made but empty. The lady is apneic and pulseless, and warm centrally. She’s incontinent of urine, which appears to be fairly concentrated. Her hygiene has been well managed. Her pupils are equal at about six mm and her limbs are supple. There is no evidence of trauma. Per the CNA, the patient is normally conversant and ambulatory, and her history includes a recent minor stroke and mild dementia. There is no emergency care in progress, and the ECG reveals asystole.

The CAN is tearful. She says the lady’s husband occupied the opposite bed until he died in his sleep two weeks ago. Until that time, this woman had supervised every detail of his care. Since then, she has become withdrawn and reclusive, and has stopped eating. She has been discovered alone on several occasions talking in full sentences as though conversing with an unseen companion. Last night, the director of nursing services informed the patient her husband’s bed had been assigned to an incoming female resident. And finally, at six this morning, the oncoming shift discovered her unresponsive. There are no known relatives, and according to the DON there is no advance directive on file.

You contact your medical direction for a pronouncement, and a young ED physician directs you to resuscitate and transport.  

Q. Any suggestions for handling these things? Considering the history and the ECG, the idea of resuscitation seemed all wrong. But our protocols are clear. In the absence of signs of obvious death, like rigor, decomposition and the like, and without a DNR order, we’re supposed to code people. Still, if we’d have contacted a doc with some common sense, I’m sure they would have pronounced.

A. I really sympathize with you. Some people are living. Some are dying, and some are dead. We do our very best to prolong the process of living and interrupt the process of dying. We can’t do much about death. It sounds like we agree: this woman was dead when you arrived.

Q. No doubt about it. As the Munchkin said, she was “really most sincerely dead”. So, how could we have gotten that across to this young doc?  

A. Anytime I’m trying to communicate with someone who acts like they’re on nitrous, I wonder if I’ve miscommunicated something—maybe omitted a piece of information that’s essential to a good decision on their part. I accept the responsibility by saying I think I’ve failed to communicate, and then I repeat what I think are the critical details. That way, I don’t insult their intelligence. Anytime you insult a listener, I think it’s like turning off their ears.

Q. We tried repeating ourselves, to no avail. The doc was polite, but he was insistent. He clearly wanted us to resuscitate. It’s possible he hadn’t done a lot of field pronouncements; he definitely seemed nervous about it. The consequences were pretty unpleasant. The nursing staff was furious with us. And worst of all, it just didn’t seem fair to the patient.

A. Sorry you had to go through that. Fortunately for us all, inexperience is not an offense. But there’s one more technique you can try if this happens again. After you’ve tried to repaint the picture for your doc, if he or she still isn’t on the same page with you, try summarizing, even bluntly. Physically insulate yourself from the rest of the call, and say something like, “Dr. Matthews, I think this lady is dead.” (Don’t forget the period, there.)

You never know what else may be going on around the physician at the time of your call. Sometimes you have to provide the necessary stimulus to help a busy ED physician focus clearly on your situation. And, sometimes the answer will still be no.

Q. I’m pretty sure we explained our perception that this was going to be a futile exercise. The doc simply wasn’t having it. I just don’t think he has much of a grasp for what we do.

A. Well, a little frustration never killed anybody. You did some extra work on this call, but you didn’t say the lady regained pulses. I hope you had a chance to visit with the doc afterward, and ask him what he was thinking. I hope you really listened to his response.

In the end, we’re all just people. Sometimes the best you can hope for is to facilitate a future call for somebody.

Thom Dick has been involved in EMS for 41 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of the EMS World editorial advisory board. E-mail boxcar_414@yahoo.com.