To resuscitate or not (bus stop spin off)

[Kiwiology]

Well said Mike; I wonder who people are really satisfying when they say "but we have to try!" - the patient or themselves without knowing it because somehow making the decision to not resuscitation somebody is unfathomable on some subconscious level to them

Six years ago when my dog was sick and dying she went to the vet and got put to sleep yet declining resuscitation for somebody who is housebound, in constant pain and dying from some end stage disease attached to a bunch of pumps for meds 24/7 and needs help to pee, poo and shower is unfathomable to the human psyche

Same sort of thing really here; you take somebody who is dying and hey they die, yet there is some sort of "thing" which says "we have to try and bring them back!" ... why? where is the logic in that?

Edited May 14, 2012 by Kiwiology

[craig]

Well said Mike; I wonder who people are really satisfying when they say "but we have to try!" - the patient or themselves without knowing it because somehow making the decision to not resuscitation somebody is unfathomable on some subconscious level to them

Six years ago when my dog was sick and dying she went to the vet and got put to sleep yet declining resuscitation for somebody who is housebound, in constant pain and dying from some end stage disease attached to a bunch of pumps for meds 24/7 and needs help to pee, poo and shower is unfathomable to the human psyche

Same sort of thing really here; you take somebody who is dying and hey they die, yet there is some sort of "thing" which says "we have to try and bring them back!" ... why? where is the logic in that?

could not agree with you more Kiwi, but unfortunately we dont have that option..... yet....what we do have is a legal and ethical responsibility to attempt to preserve life (ie save some one) if there is NO produced NFR or there is no verbal declination of the pateint.

As for the family, we can tell them that if they have been asystolic for some time, that maybe it would not be fesible for any attempt to be made and it would only casue more distress to them....this may suffice....

Our protocols state that we can withhold resusitation if the pateint has an end life plan

Edited May 14, 2012 by craig

[the_negro_puppy]

Unfortunately here in Queensland our scope to not resuscitate isnt as liberal in Kiwi land. Chronic disease or quality of life has no factor for us. I cringe every time I go to an arrest in a Nursing home or the like. The first thing I do is check for rigour, lividity, ANYTHING to prevent me pumping on the chest of the 89 year old bed bound dementia patient's chest. Most of these patients do not have Advanced Healthcare Directives (AHDs). Unless the patient has a no resus order or has had a downtime greater than 10 minutes with asystole, or obvious death/injuries incompatible, we are compelled to attempt resuscitation. It shocks me in this day and age that so few people have AHDs. I've even transferred a jaundiced barely conscious/breathing end stage liver disease pt from home to palliative care at hospital. She was expected to die at any time but at the last minute the family decided they couldnt cope with her dying at home. I was sweating the whole time in the back of the Ambulance and while 'ramped' at the ED as the family had no AHD in place.

[DwayneEMTP]

...What about the guy who sits in his recliner all day attached to an oxygen machine and continuous pump driven hospice meds, needs a carer to feed, toilet and shower him and who has not left the house in three years? Where the fuck is the point in coding him?...

You'd have to ask him to know.

So the value of exerting the effort for CPR boils down to Kiwi's perception of one's quality of life?

And can you put that value into a protocol for me? I'm guessing it would sound something like, "I can't define quality of life, but I know it when I see it!"

What happens when Dylan codes, and you know from previous experience that he's living no kind of life that you consider to have quality? Does he not receive resusc attempts based on being autistic?

Grandma that chooses to get up every day despite her mental and physical frailties? I mean, hell, she's never going to golf again, let the bitch go.

And how will you judge that quality of life to make such a decision? Dispatch rarely knows what's going on, you can almost never get a decent story from people on scene. What information are you going to use to make your decision?

If I code in my living room I will gladly sell my soul and suck dicks in hell for eternity for the right to pry my eyelids open for just a few more minutes to see Babs and Dylan before I pass into nothingness.

I get where you're coming from, and I like the argument and discussion, but I find everything about choosing to work or not work on someone based on an outsiders, particularly a friggin' medical provider's, perceived quality of life offensive.

It's important to me that you all understand that my comments are not meant to be a holier than thou thread killer. I'm trying to be clear in order to contribute, not to try and pretend that I'm morally and ethically above such a conversation.

Hopefully such bullshit would never fly with this crowd anyway...

Dwayne

[paramedicmike]

Only "rah rah bullshit" flies with this crowd, Dwayne. Regular, run of the mill bullshit? Not so much.

[Just Plain Ruff]

What I want to know is this Who gets to make the decision of who gets worked?

Is it the medical professional on the scene who has had a relationship with the patient that they are going to decide life or death for lets see like 3-4 minutes or is it someone else?

I mean how can we as medical professionals decide who gets worked based on quality of life?

is there some sort of formula that we are going to fill out?

And we better have it filled out quickly because in an arrest situation every second counts.

Or do we go around to everyones house in a proactive situation and fill it out and then it goes in a database or does it get filled out by social workers or others?

Who fills out Dwaynes or mine or paramedic mikes because seriously, they have to be worked sometime as well.

So who makes this God like or Take god out of it "ultimate life over death decision" to work someone or not.

I said it in a previous post, there was one man who thought he knew best, his name started with an A. There are many many others who also thought they knew better. Others just killed you.

We as providers, unless we have specific procedures/protocols/directives as to who gets worked and who doesn't then you work the person. This is one aspect of EMS where I fall into the "I'm a protocol junkie" If the person doesnt' have the obvious signs of death and I can document that or if they don't have a DNR or NO CODE order on their nursing home chart, sorry if it's inconvenient to anyone including myself, I'm going to start the code.

This is why I'm such an advocate for end of life decisions and paperwork to outline what I want to have happen to me when I pass on. I don't want to be coded, I actually have a Advanced Directive. I stopped short of a Do Not Resuscitate though. My doctor didn't sign it but he would have if i would have pushed it.

[Kiwiology]

The first thing I do is check for rigour, lividity, ANYTHING to prevent me pumping on the chest of the 89 year old bed bound dementia patient's chest.

Can't you get out teh ambophone, ring up the QAS Medical Officer and be like "dude, seriously, I'll get you a tray of Fosters if you let me decline to work this lady!" ?

And how will you judge that quality of life to make such a decision? Dispatch rarely knows what's going on, you can almost never get a decent story from people on scene. What information are you going to use to make your decision?

Most people here are fairly good with their story, they will tell you Nana or Pa is dying from whatever disease when asked about their medical history; and if they don't somebody who is housebound or bedbound generally has a pharmacy worth of meds somewhere fairly evident, maybe a home oxygen machine, some med pumps, a PEG tube, a catheter, a walker or wheelchair or something, you know it's going to be quite obvious they're pretty bloody crook and if it's not then the family usually tell you when you ask

In unclear circumstances if you're not sure you can always start to work them and have somebody nick out to ring up their GP to obtain more information, that's not uncommon here for various things (not just cardiac arrest)

What I want to know is this Who gets to make the decision of who gets worked?

Obviously it's the crew on scene at the time

Edited May 15, 2012 by Kiwiology

[chbare]

I'm not sure you've really answered the question. It seems quality of life is still your opinion. Or as Dwayne already stated: "So the value of exerting the effort for CPR boils down to Kiwi's perception of one's quality of life?" Can a person with a chronic, debilitating condition that requires extensive support still have a rich and vibrant life that said person would consider "high quality?"

[Kiwiology]

It's obviously in the best-informed opinion of the attending ambulance crew

[Just Plain Ruff]

But that opinion is formed in what period of time? 30 seconds? 1 minute? How can they decide what that persons quality of life was in that 30 seconds that they have had with the patient. Seems like they better make a pretty good decision.

What if their decision is wrong?

This discussion is so important. This is why end of life discussions with your family are so important. There is no getting around the fact that some of us may die alone with no one to help guide the responders in whether we are worked or not, no one to give the responders the DNR or no code blue forms and we will have no choice but to be worked. but.....

But there is a way for our final wishes to be carried out. we can have a end of life discussion with our families, and it's never too soon. Discuss your wishes and what you want to have happen. Be in agreement. My wife knows my wishes. Will she follow them when the time comes, only time will tell but she knows that she doesn't want Dwayne or Dfib or Tylerhastings to come knocking down my door and start pumping on my chest, she knows my wishes and I know hers. I hope she follows them.

If not, I can't do a damn thing about it. But I hope she follows them.

But if she does, she does and my wishes will have been carried out.

Now on the other hand, If I am in the hospital and I code, then I want what can be done done, because I'm an organ donor and I stand the best chance of a good harvest in the hospital setting rather than in the field. So code me, code me code me and then harvest my organs, but don't keep me alive for vegetables sakes. Get the organs and get out. The world will be a better place with my organs in it.

Edited May 15, 2012 by Captain Kickass