91 year old female CC: Seizure (A strange situation) – Discussion

I’ve been receiving some emails from readers who would like to know what happened with the 91 year old female (DNR patient) who went into PEA as she was loaded into the ambulance.

Here is the 12-lead ECG that was captured just as she went into cardiac arrest.

Here’s another that you haven’t seen.

She died. The paramedics did not interfere.

I posted the case because as long as I’ve been a paramedic, I’ve never had to deal with this situation.

It would be very difficult for me (and I suspect most paramedics) to stand by and do nothing while someone dies, even though we can rationalize that it respects the patient’s wishes.

When I discussed this case with my girlfriend (an advanced practice nurse) it became clear to me that DNRs are not always cut and dry.

We’ve all heard the saying “DNR does not mean Do Not Treat.”

But what does it mean? Exactly?

Does it mean we treat conditions that might be reversible?

What is a “heroic” measure?

I was discussing end of life wishes with my parents several years ago (a very difficult thing to do) and neither one wanted to be on life support.

But when I changed the question to something like, “What if you were only life support for a few days and then recovered?” or “What if you were on life support just long enough to see whether or not you would recover?” the response changed to “That sounds reasonable.”

DNRs, by their very nature, simplify things that are complicated.

The subject of DNRs warrants a lot more discussion than paramedic students are getting in school.

It warrants more discussion with the people who sign DNRs, too.

Before I receive any hate mail, I am not suggesting that the paramedics did anything wrong in this case, and I am not suggesting that this woman’s ribs should have been crushed.

I’m saying that the paramedic curriculum should spend more time on health care ethics.

I’m also suggesting that EMS protocols that say “DNR patients don’t go on the monitor” might be problematic because the ECG can be helpful in diagnosing a lot of reversible conditions.

There are shades of gray in the field of ethics and I’ve noticed that paramedics often demonstrate an intolerance of ambiguity.

As Einstein said, “Things should be made as simple as possible — but not simpler.”

7 Comments

  • Christopher says:

    I’ve been in that situation once before: unresponsive hospice patient (nurse on her way), end stage renal failure, idioventricular at 50, no radials, weak carotid. Once the hospice nurse arrived, we discussed with the family the likely outcome, obtained a refusal.

    We came back in an hour for a cardiac arrest, found the nurse left for some reason. We quickly and quietly confirmed asystole and spent the rest of our time with the family trying to support them.

    Very surreal situation to be in, especially at my age. Ultimately it helped me with hospice situations in my own family though.

  • Jenny says:

    I have to agree that EMS curriculum needs to spend a little (or a lot) more time on DNR’s and living wills. As care providers, we in the field could also help people be more proactive by making information on living wills and advanced directives available. Many states provide help guides free of charge through their department of human services.

  • Medic 22 says:

    This just happened to me. A 70 something year old patient, in hospice care for an unrepairable abdominal aortic aneurysm. I was called to the scene for acute abd pain. Med control advised us to adminsiter 5mg of Morphine IM. Shortly after she went into VF and died. However, it was at home, as she wanted.

  • Medic 46 says:

    You’re right. DNR doesn’t mean do not treat, however, where do you draw the line. A patient or family has a right to make a decision and have it respected. I don’t mean to sound cold, but what is their quality of life at that time? Are they severe Alzheimer’s, end stage CA, etc. Are you going to make their life better or worse by treating a reversible condition? As cold hearted as I sound, I’m not. I’m going through the same thing with my father and it’s the hardest decision we’ve (family) had to make but sometimes you just have to respect a patients wishes and let them die.

  • Benga_UK says:

    any chance of your professional opinion on the 12 lead??

  • David says:

    I must say since “Hospice” has been mentioned in this topic, I do believe that they need to do more teaching to the pt’s family about what to do in situations of expected cardiac arrest. The family does not need to call EMS, but instead to call their Case Nurse. It puts EMS in a situation that we don’t need to be. What about those pt’s who have a DNR but reside in Nursing homes? Those Nurses need to be better informed on when to call also. I understand DNR does not mean do not treat and is for EMS personel, but why can’t we have just 1 universal form, one form for DNR’s. One for EMS and Hospital. They basically say and mean the same.

  • Scott says:

    Do you think the entire scope of DNR’s is going to change in the next year or two considering that we are moving away from Intubation as rapidly as we are especially in the patient who is NOT in cardiac arrest?
    I could see encountering a patient who instead of a DNR patient was a “Do Not Initiate a Pulseless/Apnec Protocol” but that would be quite the document, huh?

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