This fact raises issues for pre-hospital emergency care practitioners (EMTs, Paramedics and Advanced Paramedics). Patients, having an end-of-life wish to die at home, may be transported in an ambulance and become acutely unwell en-route. Despite an agreed care plan patients, when close to death, may become clinically distressed. If this occurs when clinical staff are not present, relatives sometimes become concerned and a conditioned reaction is to ring 999 or 112 for emergency medical assistance.
The main focus of pre-hospital emergency care practitioner training is the management of acute emergencies. The ABCDE mantra enables practitioners to remain focused when the situation presented is catastrophic. As a result, when an airway, breathing or circulation problem is identified the practitioner reacts with purposeful aggression to maintain life.
The practitioner, either transporting or responding to a patient in the end stage of terminal illness, is faced with a dilemma; to resuscitate or not to resuscitate! The 3rd Edition Clinical Practice Guidelines (CPGs) attempted to address this issue by inclusion of an end-of-life decision process in the ‘Recognition of Death’ CPG.
Practice experience and feedback from practitioners indicate that if an actively dying patient becomes acutely unwell in their presence the ‘Recognition of Death’ CPG does not give clear clinical direction. A new CPG (End of Life – DNR) has been developed by PHECC to address this issue.
The ‘End of Life – DNR’ CPG permits the actively dying patient to die with dignity as well as giving clear clinical direction for practitioners. Death is a sacred moment for both the patient and relatives. Engaging in futile treatment, such as CPR, does not respect the end-of-life choices agreed as part of the advanced care planning. These choices are not made lightly and the clinical judgement of a medical practitioner will significantly influence the decision of DNR.
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The CPG requires practitioners to have ’recent & reliable written instruction from the patient’s doctor stating that the patient is not for resuscitation’ prior to transportation for a planned ambulance journey.
The CPG also requires practitioners to have ‘recent & reliable evidence from a clinical source stating that the patient is not for resuscitation’ to permit withholding of CPR, following a request for emergency medical assistance (999 call).
PHECC acknowledges the advice and guidance from Dr. Regina McQuillan, Palliative Medicine Consultant, during the development of the End of Life – DNR CPG.
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