Interfacility Transfers, DNRs, Choices

I recently recieved an email from Jamie Davis, The Pod Medic, about a dilemna one of his listeners faced on a recent call. Here is the story he recieved:

This happened to me last month and I’ve been asking around trying to get other people’s opinions about what they would have done, so let me know what you think and feel free to put it on the show…

The EMS I’m working for (Hospital Name Removed) also does non-emergency transportation for the hospital. We had a patient about two weeks ago that we were to transport to hospice after being discharged off of a treatment floor. We transferred the patient to our stretcher and began the transport to hospice when the patient began to exhibit signs of respiratory distress.
Now, herein lies the ethical dilemma:

1. The patient’s file contained a DNR, but not with a signature from a responsible party. The DNR was “confirmed” by an RN talking to someone over the phone. It was also not co-signed by another RN or MD.

2. The patient was exhibiting moderate to severe distress, including multiple brief periods of apnea, but was not in a resuscitation situation.

3. I made a judgement call to return to the hospital’s ER to have the patient re-evaluated, per our protocols, which was agreed to by both my partner and our supervisor after talking to him on the phone for on-line control.

4. The ER sent us right back up to the treatment floor without any other treatment, and that began an argument between the nursing staff on the treatment floor and my crew. The nurses on the treatment floor said that the MD attending the case has expressly instructed that the patient was to “leave and leave now” for undisclosed reasons, and that they ensured she was stable before we left. My partner and I felt that this patient was not dynamically stable and needed to be re-evaluated before transport. We then transferred the patient back to a room on the treatment floor and left the floor. Our supervisor informed us about 10 minutes later that we were to meet him on the floor and we would re-evaluate the patient’s condition to determine transport options. We met our supervisor and completed a re-eval of this patient, only now being told by the RN attending that the respiratory condition of this patient was normal and not an anomaly. Our supervisor then indicated that he was okay with the patient being transported if we were. My partner and I agreed that
we would again attempt transport, but if the patient’s condition worsened, that we were going to return to the ER for stabilization per our protocols and NOT attempt a third transfer.

The nurse was hesitant to agree to this, but eventually did and we were lucky enough to make it to the hospice center without an incident. My partner and I were both very relieved that the patient did not die in the back of the ambulance, but we were at a loss as to why a transfer would be scheduled the day before Thanksgiving in the
evening, which is prime rush hour in our primary service area. The lack of concern for the patient’s well being was a little unsettling as well.

I couldn’t help wondering if there was a better way to handle this situation
and I’m curious to see what you think. Thanks for taking the time to read this and please let me know if there’s anything that isn’t clear.

***

Warning: My answer is rambling and full of tangents.

Interfacility transfers are a true grey area in EMS. Here in our state we are finally developing a program with regulations to address some of this, although final approval and enactment may be some time away. But all EMS systems should have these issues addressed to prevent the field medics from being put in situations like the above. Without regulations, hospitals will continue to ship people out without the “t’s” crossed and the “i’s” dotted just to clear up beds.

Anyway, I probably would have done just what the medic above did. On the unsigned DNR issue, the interfacility transfer gives you less leeway to do the “right” thing than maybe a scene call does. I have, rightly or wrongly, on scene calls accepted DNR paperwork that might not have had all the i’s dotted because I felt the intention was clear. While the paperwork may have been ambiguous, there was nothing ambiguous about the scene — a terminal patient who was asystole, a family in agreement with a loved one that he die in peace. The fact that the physician signature wasn’t fully dated became a detail noticed and then forgotten. When I wrote my paperwork up, I wrote the scene up “blacker than greyer,” if you know what I mean. I’m not saying I didn’t write it up accurately. What I am saying is that paperwork is black and white, while the decisions we make are often grey. You can’t write the patient had a hint of rigor mortis in their jaw, in the paperwork, they had rigor mortis. An “i” that is not dotted might become a detail not noted in the paperwork if you chose to accept the paperwork.

A newer medic, told me the other day about responding to a deceased patient with a DNR that was not properly signed, he chose not to initiate CPR, but to call medical control to ask permission to presume, thinking it would be a forgone conclusion, only to be told to implement full ACLS resuscitation and bring the patient to the ED. This happened just days after he was castigated by another physician for putting CPAP on a patient in respiratory distress, who was a DNR. Seeking counsel from supervisors and older medics, he recieved answers ranging from you have to work the patient to you shouldn’t have called medical control, you should have just called the patient dead.

It is ethically grey. When you are the lone medic, you can chose where to draw the lines by yourself, but once others are involved, the line tends to be drawn more legally than ethically. People act out of legal concern rather than ethical concern — they are forced too.

Medics are constantly being put in these dilemnas.

Here’s a case that happened a few years ago. An experienced medic is doing an interfacility transport of an MI patient, taking him from a small hospital to a hospital capable of doing an angioplasty. En route to the hospital, the patient arrests. The medic is faced with the choice — do I bring the patient back to a small hospital or do a continue on to the larger hospital? The distance is grey. It is wherever your line is in making the decision. It might be a little closer to the small hospital, but the big hospital has the angioplasty. What do you do? He went to the big hospital and caught massive shit and was suspended. I would have probably done just what he did. He was put in the situation, not me or any other medic. He got suspended for his choice.

When I was a new medic I responded to a child hit by a car in front of a trauma center. My choice was take him to the trauma center or go another five minutes more in another direction to the farther trauma center which had pediatric specialists. I went to the closer center. When the farther trauma center called my supervisor to give him hell, I was lucky he defended me. Had I gone to that trauma center, no doubt the closer center would have been on the phone. When a patient dies, you are in a no-win situation. We can always be second guessed.

Before we get to the case outlined above, here are two interfacility cases I was involved with that raise somewhat similar issues — doing what you think is right versus what is allowed under the technical rules.

A small hospital calls to transfer a shooting victim to the trauma center down the street. They stabilize the patient by putting in IVs, a chest tube and intubating. I arrive, and not being trained in chest tubes, request a nurse to accompany us. They are overwhelmed, understaffed and don’t have anyone who can go. The man needs the OR. They give me a quick lesson on the che
st
tube and I transport the patient hoping nothing happenes to the tube. I’m putting myself on the line. Why should I do that? Maybe because there is a man dying in front of me, and somebody has to think about him. He didn’t have time for us to sort out the rules.

Another call, we are called to take a 16 year old patient home to die(although curiously she wasn’t a DNR). The patient has two chest tubes and is on some wierd kind of ventilator that sucks oxygen like crazy. While she is going home, there will be two private critical care nurses there. Her heart rate is in the 160s. This is normal for her — in her state. I’m not real comfortable with this transfer, even though I have a nurse going with me. The nurse, who is a respiratory specialist who works for the company that makes this almost one of a kind ventilator, says he knows a little something about chest tubes. It is rush hour. I ask my partner to do the transfer with easy lights and sirens. I am worried we will run out of oxygen. When he makes this request, the dispatcher goes nuts. You can’t go lights and sirens on a transfer home! she screams over the air. If you are uncomfortable, bring the patient back into the hospital. The dispatcher knows nothing about the specifics of the call. I can’t explain to her over the radio because the family is right there and the mother is already upset about everything. How is it going to make her feel if I tell the dispatcher the woman’s daughter is dying and it is the family and the hospital’s wish that she spend her last days at home and not in the hospital where she has spent the last six months. I can’t bring her back to the hospital because she is in the state they know she is in. (This is her norm.) What a mess for everyone that will cause. Okay, just go, I say to my partner. I catch shit from everyone about wanting to go lights and sirens on a transfer home. I don’t even bother to explain. Like the case above, fortunately the patient doesn’t die on us or run out of oxygen.

As a newer medic at that time, I didn’t want to rock the boat. I didn’t want to make the company look bad, upset the family or appear inadequate. Maybe in retrospect on arrival now, I would be on the line with a supervisor before I put the patient on my stretcher.

Enough rambling. The bottom line is this — Prehospital people need to be protected by clear interfacility guidelines. Hospitals probably never will, but need to work within the rules of the system. As medics or EMTs we should make certain all the paperwork is in order before we put the patient on our stretcher. Still though, there will probably still be grey situations when the interests of the patient clash with the contrictions of the system, and we will be left with doing the best we can, and always wondering how we could have done it better.

***

The Medic Cast

10 Comments

  • Anonymous says:

    What I’ve not fully understood is the laws regarding interstate transfers of patients. I have a license in just one state, but do some part time work for a service that transports routinely to four or five nearby states. Who governs us then? Who’s rules do I follow? Our medical director isn’t licensed in those states, so what good do protocols do when I’m out of the territory? If I call for orders, can I even legally perform the tasks asked of me?

    And it gets grayer for EMT-Bs and Is. In my state, Bs can’t perform blood glucose testings. But in the state next door, they can if they’ve been trained. So what happens when a B in the state with the larger scope of practice comes to my state? Can they do the blood sugar tests legally on a transfer?

    There’s so much more behind the scenes that I don’t understand and often wonder about as we drive into cities I know only by name, to meet people I will never see again with critical patients.

  • wa_emt says:

    Although I suppose it varies from state to state, a DNR order is not valid unless it has a doctor’s signature.

    Whenever I’m picking up someone from a hospital, espescially someone going to a hospice, who I’m told is DNR, I go through paperwork and make sure there’s valid orders and/or the Washington state POLST form that covers end-of-life treatment options.

    Of course, a DNR doesn’t mean Do Not Treat. Give someone with increasing respiratory distress more oxygen, contact medical control (Preferrably the patient’s doctor at the hospital) to decide what to do from there.

  • Paul says:

    Emergency Medical Treatment & Active Labor Act (EMTALA) found at http://www.emtala.com will give some insite and protection to transportations.

    This is act basically says that the MD is responsible for that patient until this patient is in the hands of the accepting facility. This is an area where dispatchers are required to get the accepting MD prior to transportation and I can assure you that the company that I work for does just that. This ACT is the law and is your protecting on transportation of patients inter-facility. The facility sending that patient MUST adhere to these rules, if something happens to the patient enroute and the paramedic or EMT has expressed concerns to the sending MD that they are not confortable with the stability of the patient then all liability falls on the MD that is sending the pateint.

    This is a very interesting law as I have been becoming very accustomed to it since we have an issue with a childrens hospital in our state that sends psychiatric children with us to a mental health treatment facility, but does not allow the EMS personel to read ANY of the paperwork pertaining to the patients medical history or current diagnosis. They feel this is a HIPAA violation.

  • Paul says:

    Emergency Medical Treatment & Active Labor Act (EMTALA) found at http://www.emtala.com will give some insite and protection to transportations.

    This is act basically says that the MD is responsible for that patient until this patient is in the hands of the accepting facility. This is an area where dispatchers are required to get the accepting MD prior to transportation and I can assure you that the company that I work for does just that. This ACT is the law and is your protecting on transportation of patients inter-facility. The facility sending that patient MUST adhere to these rules, if something happens to the patient enroute and the paramedic or EMT has expressed concerns to the sending MD that they are not confortable with the stability of the patient then all liability falls on the MD that is sending the pateint.

    This is a very interesting law as I have been becoming very accustomed to it since we have an issue with a childrens hospital in our state that sends psychiatric children with us to a mental health treatment facility, but does not allow the EMS personel to read ANY of the paperwork pertaining to the patients medical history or current diagnosis. They feel this is a HIPAA violation.

  • Anonymous says:

    paul, thats definitely not true, and HIPAA regulations make it very clear that information exchanges between providers when transitioning care are legal.

    When I worked an interfacility bus, I would refuse to do transports unless I was provided with the patient’s history. I needed it not just for medical reasons, but for billing documentation purposes (The cost of an ambulance transfer has to be justified to the pt’s insurance or my company just lost $1500).

    DNRs are a very grey area in EMS. Again when I worked transfer buses, I always made sure I had all that paperwork DNR stuff, the t’s and i’s, in order before transporting. Its important to CYA before you even see the patient when you can.

    If there was ever any question or documentation missing, I got it taken care of before seeing the patient.

    If I’m ever in the situation where I’m uncomfortable in transporting a patient in odd circumstances and I have a supervisor who tells me its fine, I’m not going to risk my card on it. His/her name can go on it and he/she can do the transport.

    I got bit once where I did as a BLS transport crew a patient who ended up during transport needing deep suctioning of his trach (ALS only skill here). While nothing negative happened to the patient (we just lit it up to the receiving facility and they suctioned him on arrival), it was not a situation I was being put in again.

  • Anonymous says:

    I have run into that sealed paperwork crap. I just open it right in front of the nurses. Once, they had a sealed envelope containing some papers and also a smaller sealed envelope within it. The smaller envelope had some further psych history stuff. It’s like the double secret launch codes on the submarine or something. I got the “She’s stable. Why do you need to pry into her history?” look. To which I gave the, “Because it’s my patient now, mofo” look.

    Sometimes people seal it, tape it, and sign across the tape. I want to tell them that this kind of stuff is the domain of college admission boards and Shakespearian kings, and if it’s the latter, get a wax seal and get over with it.

  • Anonymous says:

    While I think knowing a pt’s diagnosis hx, current medications, etc is important, I wouldn’t really consider notes from a pt’s psychotherapy session really necessary for me to read, so I could understand if those are sealed.

    But I should have access to their med/psych history, medications, allergies, etc etc.

  • Paul says:

    Yes, I agree and that is what we are fighting with the Hospital is that the information is infact our business and the hospital is not allowed to restrict it from us. My comment last night reflects that the childrens hospital is saying this, but it is not true and we are trying to prove it to them.

    Opening it up in front of them is a sign of “because I can” and only makes nurses angry when it is unnessecary. If there is a W-10 with the Pt history and if you ask the specifics to the RN is there any chance of violent behavior or sexual behavior then I am confortable with opening the envelope in the ambulance so not to urke the RN’s. I will then write up the incident later for my supervisor to take care of. I aggree with the comment about the need to know the psych history, there is no need for me to read or know the psych notes on the patient. I am not a psychologist nor a therapist. If the paperwork has the history, present dx, meds allergies…that is all I need to know. Otherwise, I am just being nosey, cause the rest does not reflect my job or what I have to do in the back of the bus.

  • Anonymous says:

    I guess what it comes down to is that until I open it, I can’t verify if it’s something that I need to know. It’s like some medical Heisenberg uncertainty principle — the act of opening it may reveal that I don’t need to know it, but until I open it to find out, I don’t know if I don’t need to know it.

    Other allied health professionals might think that I don’t need to know something, and I might think that I do need to know something. It’s their job to know what they need to know, and mine to know what I need to know. So if they don’t do my job, I can’t always trust that they’re giving me all the proper info.

    I hate to play into it by waiting until I get to the truck to open the envelopes. That’s kind of a second fiddle approach.

    They trust me with this person’s care, but they don’t trust me with information about this person.

  • PC says:

    Thanks to all for your excellent and provoking comments. I will be investigating this issue more and reporting on it, as our region gets ready to pass our critical care program.

    PC

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