How should paramedics handle end-of-life wishes?

If there are no medical orders or they can't be found, first-responders are professionally bound to begin life-saving interventions and transport to a hospital even if family members say otherwise. (Credit: iStockphoto)

Paramedics and emergency medical technicians are trained to save lives. But they sometimes encounter situations where a dying patient’s end-of-life wishes contradict their professional code.

Interviews with EMTs and paramedics suggest clear guidelines and more training are needed.

“One way to gain perspective on these crises was to interview the paramedics and EMTs involved in them,” says Deborah Waldrop, a professor in the University at Buffalo School of Social Work.

“We are not born into this life knowing how to die or knowing how to care for someone who is dying.”

Waldrop has interviewed hundreds of families through a 16-year collaboration with Hospice Buffalo, trying to better understand the psychosocial needs of patients and their families faced with a life-limiting diagnosis.

People don’t know what to expect watching someone die. Providing end-of-life care, in fact, can be among the most stressful human experiences. Emergency calls are often a way of coping with that stress, especially when a patient’s symptoms change suddenly for the worse.

“We are not born into this life knowing how to die or knowing how to care for someone who is dying,” Waldrop says. And first responders are not trained in end-of-life care, yet do a lot more end-of-life care than they get credit for. “They have to,” she says. “They’re usually the first medical personnel on scene.”

6 ways families can be prepared

The results of the interviews, published in the Journal of Pain and Symptom Management, suggest that many paramedics have developed their own ways of managing end-of-life situations, including coaching the family through the process and clarifying what’s happening.

“They fill the void for families looking for help, looking for knowledge about what’s happening, and what to do,” Waldrop says.

If there are no medical orders or they can’t be found, first-responders are professionally bound to begin life-saving interventions and transport to a hospital even if family members say otherwise.

“It’s why the end-of-life conversation needs to happen at the time of a life-limiting diagnosis or when something changes on the trajectory of that illness and why those documents have to be in a prominent place,” says Waldrop. “In the heat of the moment, families don’t want to be shuffling through files. It’s someone’s life that may end differently than they intended if we fail to take these steps,” she says. “Those memories don’t easily go away.”

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These calls are low frequency, but high intensity. Events happen quickly. First responders assess the patient, family, and environment, identifying relationships to establish who might be serving in a decision-making capacity. The emotional intensity of the environment also raises safety concerns.

“The death of a loved one can bring out the worst in people,” says Waldrop. “Emergency personnel have to be mindful of the scene.”

Waldrop offers several steps families and patients can take when facing end-of-life decisions:

  • Follow the diagnosis of a life-changing illness, initiate conversations about the person’s goals of care and wishes for life-sustaining treatment.
  • Ask health care providers about what to expect over the course of a chronic, life-limiting illness. Information is key to making choices and upholding a person’s wishes.
  • Revisit the person’s wishes periodically and when the situation changes, such as after a symptom crisis or hospitalization.
  • Discuss wishes for resuscitation (or not) with all caregivers who are involved.
  • Assure that all family members (those who are caregiving and those who are at a distance) are aware of the ill person’s wishes.
  • Place copies of a Non Hospital Do Not Resuscitate Order or Medical Orders for Life Sustaining Treatment (MOLST) in a prominent location such as on the refrigerator.

Source: University at Buffalo