Correspondence
Palliative Care Protocol
Barbara Pavey, RN Incorrectly Interpreted as Normal?
Mark J Towers, MB, FRCR Is Activated Charcoal Useful for Acetarninophen Overdose Beyond Two Hem's After Ingestion?
Howard C Mofenson, MD Thomas R Caraccio, PharmD/ S RutheoCoord Rose, PharmD William A Watson, PharmD Gary M Oderda, PharmD, MPH Richard L German, MD Wendy Klein-Schwartz, PharmD
1 66/893 I
Palliative Care Protocol To the Editor. I found the editorial "Development of a Palliative Care Protocol for Emergency Medical Services" [December 1991;20:1383-1386]to be interesting reading. The question of palliative measures also was a sticking point for the Los Angeles County Emergency Medical Services (EMS) Agency in the development of our policy on prehospital do-not-resuscitate (DNR) orders. Using the state's guidelines1 as our ethical as well as medical model, we held fast to the belief that dying patients should not be kept beyond the EMS pale. We insisted that our policy affirm that EMS personnel provide these patients with any and all interventions, short of resuscitation, to ease their pain and suffering. In our early discussions of this issue with advanced life support provider representatives, we were shocked and angered to hear some of them say, "If our people are called to a DNR scene and the patient is still alive, we're going to tell them to pack up and leave." These provider representatives defended their position by reminding us that they had been trained to save lives, not "stand by and watch people die," and that deprived of the chance to do everything, they would do nothing. Shock and anger abated as we looked at some of the reasons behind this response. Most of the providers who voiced it were older
supervisors who had not actually worked as paramedics for a number of years. In conversations with younger, working paramedics, we found considerable support for a policy that would allow them to treat dying patients and honor DNB orders at the same time. The supervisors had been trained in the early days of EMS, when success meant saving lives and failure was equated with death. They were also worried that paramedics might be called out repeatedly to provide hospice care for dying patients. Finally, they were hamstrung by years of following the EMS agency's own policies, which heretofore have required aggressive resuscitative attempts on all but "obviously dead" (rigor and iividity, decapitation, incineration, etc) patients. A cooling-off period ensued during which soul-searching and consciousness-raising occurred on both sides, resulting eventually in a policy draft that respected the rights of both patients and providers. To allay fears about repeat calls, we added a transport option to the policy, based on the assumption that in most cases involving dying patients, a call to 911 is a call for help, signaling the layperson's inability to deal with the dying process. Before implementing the policy, the EMS agency will offer mandatory training for emergency medical technicians and paramedics in both the letter of the policy and in the spirit and larger context of patient self-determination and new ways of viewing death and dying.
Our prehospital DNR policy draft is likely to be approved soon. As anyone who has been through it knows, the process of developing a prehospital DNR policy can be grueling and intense. Many individuals and agencies have wrestled with the ethical, legal, medical, and operational complexities associated with formulating a prehospital DNR policy. In a jurisdiction the size of ours, the normally complicated policy-making process is further compounded by the number of participants, and approval will not be the end point. Massive undertakings await us in the areas of notification of physicians and patients, providing emergency medical technician-I and paramedic training sessions, and printing and distributing a standardized form. Without question, however, the hardest part of the entire experience was coming to terms with the palliative measures issue. I hope that as a result of the excellent editorial by Drs Bausch and Ramzy, EMS jurisdictions that are contemplating prehospital DNB policies will both beware and take heart.
BarbaraPavey,RN Operationsand Medical Monitoring Los Angeles CountyEMSAgency 1. State of California, Emergency Medical Services Authority: Guidelines for EMS Personnel Regarding Do Not Resuscitate Orders. EMSA, December 1990.
ANNALS OF EMERGENCY MEDICINE
21:7
JULY 1992
Palliative Care Protocol
Barbara Pavey, RN Incorrectly Interpreted as Normal?
Mark J Towers, MB, FRCR Is Activated Charcoal Useful for Acetarninophen Overdose Beyond Two Hem's After Ingestion?
Howard C Mofenson, MD Thomas R Caraccio, PharmD/ S RutheoCoord Rose, PharmD William A Watson, PharmD Gary M Oderda, PharmD, MPH Richard L German, MD Wendy Klein-Schwartz, PharmD
1 66/893 I
Palliative Care Protocol To the Editor. I found the editorial "Development of a Palliative Care Protocol for Emergency Medical Services" [December 1991;20:1383-1386]to be interesting reading. The question of palliative measures also was a sticking point for the Los Angeles County Emergency Medical Services (EMS) Agency in the development of our policy on prehospital do-not-resuscitate (DNR) orders. Using the state's guidelines1 as our ethical as well as medical model, we held fast to the belief that dying patients should not be kept beyond the EMS pale. We insisted that our policy affirm that EMS personnel provide these patients with any and all interventions, short of resuscitation, to ease their pain and suffering. In our early discussions of this issue with advanced life support provider representatives, we were shocked and angered to hear some of them say, "If our people are called to a DNR scene and the patient is still alive, we're going to tell them to pack up and leave." These provider representatives defended their position by reminding us that they had been trained to save lives, not "stand by and watch people die," and that deprived of the chance to do everything, they would do nothing. Shock and anger abated as we looked at some of the reasons behind this response. Most of the providers who voiced it were older
supervisors who had not actually worked as paramedics for a number of years. In conversations with younger, working paramedics, we found considerable support for a policy that would allow them to treat dying patients and honor DNB orders at the same time. The supervisors had been trained in the early days of EMS, when success meant saving lives and failure was equated with death. They were also worried that paramedics might be called out repeatedly to provide hospice care for dying patients. Finally, they were hamstrung by years of following the EMS agency's own policies, which heretofore have required aggressive resuscitative attempts on all but "obviously dead" (rigor and iividity, decapitation, incineration, etc) patients. A cooling-off period ensued during which soul-searching and consciousness-raising occurred on both sides, resulting eventually in a policy draft that respected the rights of both patients and providers. To allay fears about repeat calls, we added a transport option to the policy, based on the assumption that in most cases involving dying patients, a call to 911 is a call for help, signaling the layperson's inability to deal with the dying process. Before implementing the policy, the EMS agency will offer mandatory training for emergency medical technicians and paramedics in both the letter of the policy and in the spirit and larger context of patient self-determination and new ways of viewing death and dying.
Our prehospital DNR policy draft is likely to be approved soon. As anyone who has been through it knows, the process of developing a prehospital DNR policy can be grueling and intense. Many individuals and agencies have wrestled with the ethical, legal, medical, and operational complexities associated with formulating a prehospital DNR policy. In a jurisdiction the size of ours, the normally complicated policy-making process is further compounded by the number of participants, and approval will not be the end point. Massive undertakings await us in the areas of notification of physicians and patients, providing emergency medical technician-I and paramedic training sessions, and printing and distributing a standardized form. Without question, however, the hardest part of the entire experience was coming to terms with the palliative measures issue. I hope that as a result of the excellent editorial by Drs Bausch and Ramzy, EMS jurisdictions that are contemplating prehospital DNB policies will both beware and take heart.
BarbaraPavey,RN Operationsand Medical Monitoring Los Angeles CountyEMSAgency 1. State of California, Emergency Medical Services Authority: Guidelines for EMS Personnel Regarding Do Not Resuscitate Orders. EMSA, December 1990.
ANNALS OF EMERGENCY MEDICINE
21:7
JULY 1992
