Work her, or let her float to the light ????????

[crotchitymedic1986]

You respond to your local nursing home for difficulty breathing, and arrive at the scene with 10 minutes of the 911 call. The nurse is at the station completing paperwork, and tells you the patient is in room 19, bed 2. You arrive in the room to find an 86 year old female, who is bedridden, in the fetal position with contractures to arms and legs, Tube feeding running, foley and diaper in place. Pt has a history of multiple CVAs, and is a full-code (god only knows why).

She is not breathing, and does not have a pulse. Quick-look on the monitor shows Asystole in all three leads. Nurse comes to room and says "she was breathing when I called 911".

Do you work her, or let her cross over ?

[Doug]

Somebody's gonna have a sad christmas...my medcon is very good about not transporting asystole...

[spenac]

Not enough info to make that call. Perhaps the nurse is confused about her breathing or she just heard an agonal breath.

Is there dependant lividity? Are the contractures actually rigor?

If decision is to work her we work her there and if no ROSC we let the funeral home get her. There are no rolling codes.

[crotchitymedic1986]

No she is not mistaken, apparantly the patient quit breathing sometime in the last few minutes, she still has good color, no rigor, no lividity.

P.S. There is no trick, or hidden agenda, it is just a simple question: Would you work this bedridden patient, who if rescusitated will continue this quality of life. I imagine some will because of the full code status, some will not.

[spenac]

Sadly no DNR and no evidence of death legally she would have to be a full code. Asystole is not considered proof of death w/o the some other evidence of death. Work her on scene. Run the code per protocol including ACLS meds. No ROSC after 20 minutes she is covered and we allow funeral home to take her.

ROSC we then transport her to the hospital while monitoring.

While I would not want what appears to be such a lack of quality life apparently she and/or her family feel different since they do not have a DNR so she will get my best efforts to abide with her wishes to live.

[Kaisu]

It's an interesting question, and one we will sooner or later all deal with. Generally speaking, I take my cue from the family. If they are all standing around accepting of what had happened, then I will not work the code. If on the other hand, they are attempting CPR or screaming don't let gramma die... well, then we work it. (for the record, I do NOT do aesthetic CPR. It's all or nothing with me.)

This is not an option in your scenario tho. I have a general policy that it is not my job to make quality of life judgments. I know that at my advanced stage, I appreciate things that when I was younger I would ignore. Even in the position you describe, I think I might enjoy another sunset. My answer for your scenario is - I would work it. What clarified it for me was my answer to the question I asked myself "what if this was a 12 year old in a similar situation? The way my simple mind works - if I would work the kid then I need to work gramma.

Kudos for the topic.

[p3medic]

If the patient has no advanced directives I would have to make the assumption that she would want the full court press. It is not my place to decide what constitutes quality of life. These facilities are well versed in DNR/DNI and most likely had this conversation with the family and patient at time of admission.

[Doug]

I've been in this situation with a person 20 years younger living well and independent without a remarkable medical history. Put her on moniter, asystole in 3 leads called medcon and agreed not to work it. I've also gotten on scene with a BLS crew working a code, put the mon. on with asystole and did the same. I agree if a BLS crew gets there obviously without a moniter then they may be bound to work it.

[DwayneEMTP]

Yeah, with asystole, almost certainly down most of the 10 minutes, likely more unless this is an exceptional nursing facility, not going to work it unless medcon is willing to go to the mat over it.

Will obviously check for other signs of death, certainly check pupils, attach ETCO2 to shore up my case with medcon, have my partner apply PPV while I call for permission to leave this girl alone. If this is a normal temp 50 y/o it's unlikely medcon is going to refuse my request, with an 89 y/o woman it's a near certainty s/he will comply. We can't save her because her tired old body can't survive proper CPR. ROSC means nothing to her if she has no medical issues at all, in this state there is no good outcome, so we might as well do the least amount of harm.

Dwayne

[crotchitymedic1986]

dwayne, if you were on the call, do you have to call medical control to get permission not to work it, or do you have to start CPR, then call MC to get permission to stop working it ?