Out-of-Hospital End of Life Care by Emergency Medical Services (EMS)

INTRODUCTION

Many people with terminal illnesses who live at home, in residential settings, or in skilled nursing facilities do not wish to have aggressive treatments such as cardio-pulmonary resuscitation (CPR) at the end of life. While Minnesota has an established system to respect these wishes through a physician generated "Do not resuscitate" order (DNR), procedures and policies regarding the DNR order vary throughout the state. Providers, families and physicians are unclear on how to implement and use the DNR orders. Additionally, the state does not have a system that allows EMS personnel to provide comfort measures in place of aggressive treatment.

The confusion over resuscitation of a terminally ill patient can be frustrating for paramedics and emergency medical providers, and devastating for families. EMS personnel are charged with a "duty to treat" with CPR that can be in conflict with the wishes of the patient or the family. As one paramedic said, "One of the hardest things for me to do is begin CPR on a frail, obviously terminal patient knowing I will break ribs and add to the suffering."

Currently, Minnesota has nearly 300 different ambulance services, each with its own protocols. Confusing issues over the use of DNR orders include:

• Varity of forms

Use of different forms varies from area to area

• Rules for renewal

There is variation of the rules about how often DNR orders need to be renewed

• Policies and procedures in various settings

Policies within residential care, such as assisted living facilities, that automatically require resuscitation, even against a patient’s wishes or a physician’s order will vary from facility to facility

• Availability of orders for EMS personnel on arrival

DNR orders that are not readily available when an ambulance is called can cause multiple problems for EMS personnel when they arrive

Both health care providers and the public often confuse DNR orders and health care directives. A DNR order is a treatment order generated by a physician. A health care directive is a patient’s statement of preference for treatment. In an emergency transportation situation, transport personnel are not obligated to read or honor a health care directive. However, they are obligated to follow a DNR order from a physician.

RECOMMENDATIONS AND STRATEGIES

The Commission recommends that the health care systems, emergency medical systems, and the community:

• Develop a standard and simplified vocabulary around policies and portability for physician orders regarding cardio-pulmonary resuscitation (CPR) and comfort care in order to enhance understanding and implementation by EMS personnel who respond to 911 calls at private residences and nursing homes

• Educate the public and health professionals regarding the use of out-of-hospital CPR and comfort care orders

Minnesota has a system for out-of-hospital DNR orders. The implementation of this system varies and is a source of confusion for patients, families, and providers. The Commission recommends the establishment of standard and simplified language concerning the implementation of DNR and comfort care orders and subsequent provider and public education about this.