EMS World Expo: EMS at End of Life

Have you ever transported a patient to the hospital and questioned whether you did any good? Have you ever taken care of a patient at end of life and wondered whether you treated them in accordance with their wishes?

Components of traditional EMS care—9-1-1 response, resuscitative care, and transport to the ED—may not be compatible with a patient’s end-of-life wishes. They can even be uncomfortable, invasive and confusing for elderly patients and those in the final stages of illness.

Douglas Kupas, MD, EMT-P, FAEMS, is medical director for NAEMT and an EMS and emergency physician at Geisinger Health System in Danville, PA. He is commonwealth EMS medical director for the Pennsylvania Dept. of Health. Kupas presented “EMS Care at End of Life” Wednesday afternoon Oct. 12, 2022 at EMS World Expo in Orlando.

Kupas began his talk with a hypothetical scenario that he revealed later was a true call. It’s a cold winter night in central Pennsylvania, and you are dispatched for a 98-year-old female with chest pain. She’s a widow who lives at home with her caretaker. She has stable vitals and normal ECG. She is a frail thin woman in a hospital bed. What should you do?

There are rarely clear right and wrong answers in scenarios such as these, said Kupas, who urged his audience to consider both sides of the decision to transport this patient.

There has been a paradigm shift in EMS toward palliative care, said Kupas, and EMS has become the “safety net” for the end of life. Forty percent of dying patients visit the ED in the last 2 weeks of life. “We need to be good at this,” Kupas said.

EMS transports and emergency room visits can lead to confusion or agitation in the elderly. An IV can be burdensome, and lab tests and imaging can be uncomfortable and invasive. Ask your patient or family what their specific goals are for emergency care and medical testing.

Quoting extensively from Atul Gawande's 2014 nonfiction bestseller Being Mortal—which he said every health care provider should read—Kupas urged his audience to focus their thoughts of dying patients less on extending their life, and more on their wishes, well-being, dignity and what they want to achieve in their remaining time.

Kupas’ takeaways included:

• Review advance directives. This takes time and skill.
• Speak with family members and the patient’s power of attorney.
• Call hospice if the patient is in hospice.
• Question whether community paramedicine and MIH have a role in this particular case.

EMS has become so much more than mere “suppliers of transportation,” concluded Kupas, and field terminations, including delivering death notifications to a grieving family, is a skill that takes as much training and practice as an endotracheal intubation.

Kupas closed with a quote from Hippocrates to reinforce his message that EMS should not be about simply “saving” patients or extending life: “Cure sometimes, treat often, comfort always.”