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mobey

Deadly bleed and the ethical decision

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Called to a Rural hospital.

No physician available.

82 y/o male presented last night after syncopal episode.

Found hypotensive, with hx of 2 day coffee goround emesis, and hematochezia.

HGB 47

Pt on coumadin, but has not had it in 2 days INR 3.2

Pt was talking GCS 15/15 this morning, but has passed 700ml measured blood per rectum within the last hr, and dramatically decreased in conciousness.

It is now 1400 hrs.

The pt has a DNR, however asked to be transfered to the city (2hrs away) for surgery. This was at 1300, shortly therafter his vital signs changed, he became lethargic/confused and eventually losing conciousness.

Daughter agrees with plan, and wants him transfered. Physician calls you, and washes his hands of the pt.

You have the hospital at your disposal.

You enter the room to find: Appropriate size for age elderly male, lying supine with loud snoring resps.

RN in room for report and monitoring him.

He is GCS 3. (the pt, not the nurse)

Nasal cannula in place with 2lt 02 running

IV in place x2, both 18 G. One Nacl 250ml/hr. One locked.

BP via machine: 74/32, HR 132 reg (no radial), Resp 22 deep reg. Temp 36.7, BGL 10.4mmol

Pt has had 500ml Nacl

Vit K

1000ml Pentaspan

Pantaloc

All within the last 2 hrs

Nurse sts, "Dr. says he would like you to stabalize him and get him to the city ASAP."

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The patient has already stated he wants definitive care, so the DNR is no longer valid in this instance. The daughter concurs, and the doctor has requested the transfer.

So, what is the question? Or better yet, what's the dilemma.

Edited by tcripp

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I would feel that unless I witnessed the verbal recension of the DNR that you should not provide life sustaining care in the patients current state. The way that I have always understood a DNR to work is that it is a legally binding document, the only way it could be rescinded is if another legal document revoking it was presented, the daughter had either medical or a durable power of attorney, or the patient states their wishes in front of you and another credible witness (eg. your partner, or the doctor). The patients daughter may very well concur with the plan however in absence of said power of attorney there is no legal power that the daughter wields.

Now as far as the transport is concerned...as a BLS provider in my case I would refuse transport because I could not provide reasonable comfort measures based on the patients current needs. If I were an ALS provider I might consider the transfer to the "city" HOWEVER I would have the family be prepared for the worst case scenario and understand that the patient may not make it through the transfer.

As far as the nurses statement "Dr. says he would like you to stabalize him and get him to the city ASAP.", I would not do any such thing with out a WRITTEN ORDER because as we all know if it is not written down it did not happen.

Edited by TylerHastings
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But, we take verbal orders from docs all the time which are signed for by the nurse. So, to me it's all the same.

As to your comment about the DNR, that is only good if he goes in to cardiac arrest or respiratory arrest, to which he has done neither at this time.

I absolutely agree with your comment about setting the patient's family up for worst case scenario. Transport while stabilizing and if he crashes, then you have the DNR as your next coure of action.

Edited by tcripp

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But, we take verbal orders from docs all the time which are signed for by the nurse. So, to me it's all the same.

As to your comment about the DNR, that is only good if he goes in to cardiac arrest or respiratory arrest, to which he has done neither at this time.

I absolutely agree with your comment about setting the patient up for worst case scenario. Transport while stabilizing and if he crashes, then you have the DNR as your next coure of action.

For us doing something like transporting an unstable patient 2 hrs away under my protocols would require a written order and in some cases this one I am not so sure about but some cases it would require a CCT unit.

I suppose if the DNR is a simple Do Not Resuscitate or if it is a full on advanced directive.

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I suppose if the DNR is a simple Do Not Resuscitate or if it is a full on advanced directive.

The DNR is simple, I will quote it: "I Mr.X request no artificial resucitive measures, however would like standard comfort measures"

As far as a Dr asking you to stabalize; this is common around here. Consider for this scenario, you are not under legal obligation to do it, or not do it.

I would feel that unless I witnessed the verbal recension of the DNR that you should not provide life sustaining care in the patients current state

The patient has already stated he wants definitive care, so the DNR is no longer valid in this instance.

Just to clarify: He only agreed to surgery to fix the bleed. This was not a verbal order to overide the DNR.

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Ok I have a question does this pt have a DNR because he is old or because he has a terminal disease.

If it is because he is old then I would say to the family that he may not make it and do the transfer.

If he is terminal then I would think this may have something to do with the disease process and the end of life stages, but with that being said if the Dr. wanted a transfer it would be done. I do not have authority to say no, alot of the time when it comes to the above it is the family that makes it hard and they havent accepted the final decision.

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So after much hashing out of this call in the chat room...I would if I were an ALS provider get a written order from the doc ordering the transport...advise patient and family of all negative outcomes up to and including death. I would load the patient while providing stabilizing care and get on the horn with the receiving hospital as soon as possible asking the MICN to keep a doc available for consultation as needed. Then i would start to pray this guy didn't die.

I need to add a couple of things to this post...Thanks Mobey Tcripp and Katie for hashing this out with me and helping me to better understand this also thanks for helping me start thinking outside of my BLS comfort zone and thinking as the ALS provider I will be in the future.

Edited by TylerHastings

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Ok I have a question does this pt have a DNR because he is old or because he has a terminal disease.

Based on age only.

Pt's Hx is just HTN, COPD (well controled), and hypertrophic cardiomyopathy (inhereted) no decrease in ejection fraction known.

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Hey Mobey,

I maybe overthinking again...but what was the patients quality of life prior to this event?

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