EMS Medicine Live Welcome November 2015
EMS Medicine Live Vision Community & Academic EMS Physician Education Information Sharing Board Preparation Group involvement Meet and see our peers Involve your unique experiences and skills
EMS Medicine Live January Open 2016 EML Schedule February Open March Christian Martin-Gill, UPMC, Regionalization of EMS Care April Dan O Donnell, IU, Pediatric Mass Casualty Case May Darren Braude, U NM, Extraglottic Airway or Medication assistant airway management June Open July August September November December Open Cray Cooley, UT San Antonio, Board Review Topic Jeff Lubin, Penn State, Prehospital Hemostasis Chad Nesbit, Penn State, Mechanical CPR Devices Open Last Tuesday of the month at 1 PM Eastern with flexibility
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EMS Medicine Live Today s Speaker Michael Dailey, MD Former EMT, New York EMS Residency and EMS Fellowship: University of Pittsburgh Medical Center Albany Medical College Director, Pre-hospital Care and Education Medical Director, Regional Emergency Medical Org Multiple publications Use of Prehospital Naloxone
An overview of end of life care p setting g in the out of hospital EMS Live November 24, 2015 Michael W. Dailey, MD Regional EMS Medical Director Associate Professor of Emergency Medicine
Disclosure No academic conflict of interest No financial conflict of interest
Objectives Where did EMS resuscitation come from? What should we be doing for our patients? What is palliative care and what is hospice and how do they apply to EMS? When should we consider alternative ti care?
Early EMS Resuscitation
A history of resuscitation 800 BC Elijah performed mouth to mouth successfully (Kings 17:22) Young child who received the breath of life (many versions) Rescue Societies formed in Europe 1767 Dutch Society for Recovery of Drowned Persons 1774 England s Royale Humane Society
Rescue Society Resuscitation Early resuscitation techniques Inversion of victim Placing victim on rolling barrel Placing victim on trotting horse Breath of life 1500s bellows used to blow air into mouth Heat was connected with life 1700s blew tobacco smoke into rectum
The Next 50 years Different techniques of manual ventilation were tried and compared tongue stretching stretching the rectum rubbing the body tickling the throat waving ammonia salts under nose Beating of victims became less popular precordial thump remains
Finally CPR! 1940s open cardiac massage and defibrillation 1958 Dr Peter Safar experimented with mouth to mouth respirations 1960 s Dr Kowenhoven et al introduced closed chest massage
What about situations? Mechanical compressions ECMO or bypass for viable patients Cath lab while in arrest Organ donation Assisted suicide Hysterical families Billing Many more situations to consider
But that was how we got here now what?
What is the deciding factor? What do patients want? What do families want? What is safe? What do we want? What is medically indicated?
First do no harm
What do patients want? Background Studies suggest that a majority of elderly patients would want to undergo cardiopulmonary resuscitation (CPR) if they had a cardiac arrest. Yet few studies have examined their preferences after clinicians have informed them about the outcomes of CPR. Methods Older patients' preferences regarding CPR in one geriatrics i practice in Murphy et al The Influence of the Probability of Survival on Patients' Preferences Regarding Cardiopulmonary Resuscitation NEJM 1994
What do patients want? Results 371 patients at least 60 years of age were eligible; 287 completed the interview. 41 percent opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (10 to 17 percent), 22 percent opted for CPR. Only 6 percent of patients 86 years of age or older opted for CPR under these conditions. When asked about a chronic illness in which the life expectancy was less than one year, 11 percent of the 287 patients opted for CPR After learning the probability of survival (0 to 5 percent), 5 percent said they would want CPR. Murphy et al The Influence of the Probability of Survival on Patients' Preferences Regarding Cardiopulmonary Resuscitation NEJM 1994
What do families want? Study objective : To determine whether family members accept field termination of unsuccessful out-of-hospital cardiac arrest resuscitation Methods : Structured interview, in an urban, municipal, advanced life support emergency medical services (EMS) system The interview i subjects were family members present at unsuccessful out-of-hospital resuscitation attempts Delbridge et al Field termination of unsuccessful e b dge e a e d te at o o u success u resuscitation attempts Annals of EM 1996
What do families want? Results: During the 4-month study 140 out-of-hospital cardiac arrests occurred Follow-up with a family member was performed in 42 of the 53 cardiac arrest (79%) When resuscitation was terminated in the field 96% reported satisfaction with the decision Wh i i i d i h ED 82% When resuscitation was terminated in the ED 82% reported satisfaction with transport to the hospital
What do family members want? Responses indicated that 76% of those families with relatives transported might have accepted termination of resuscitation in the home In all cases, relatives reported satisfaction with the paramedics' care and with the manner in which they were informed of the victims' deaths Conclusion: Family members accept termination of unsuccessful out- Family members accept termination of unsuccessful out of-hospital cardiac arrest resuscitation in the field
Termination Rules ALS rules have 100% sens and spec Event not witnessed by EMS No defibrillation ill in EMS setting No ROSC in EMS setting Arrest not witnessed No bystander CPR (For cardiac etiology arrest only) Prehospital termination of resuscitation in cases of refractory out of hospital cardiac arrest, JAMA, 300:12:1432 8, C. Sasson, A.J. Hegg, et al Derivation and evaluation of a termination of resuscitation clinical prediction rule for advanced life support providers. Resuscitation, 74 :2, 266 275, L. Morrison, P. Verbeek, M. Vermeulen, A. Kiss, K. Allan, L. Nesbitt, I. Stiell
How well prepared are EMS personnel? No assessment tool for prehospital personnel and end-of-life issues exists 93% were comfortable with DNR orders 87% comfortable with MOLST 87% comfortable sorting out conflict between patient and family 92% had formal training about DNR orders Waldrop DP, Clemency B, et al, Preparation for Frontline End-of-life Care, J. Pal Care Med, 2014
How to improve EMS understanding? Improve EMS CME (75%) and initial education (56%) Improve healthcare provider education Improve public education about EOL Improve conflict resolution skills Improved training to handle emotional families Making protocols more clear Waldrop DP, Clemency B, et al, Preparation for Frontline End-of-life Care, J. Pal Care Med, 2014
Caring for the family when the patient is no longer the patient
Elements of an emergency end-of-life call Family responses Assessment e of the patient, event, family, scene, environment Management: age e Interventions with the patient and family Conflicts Waldrop DP, Clemency B, et al, We are strangers walking into their life changing event, J. Pain and Sympt Manag, 2015
The Family Whether it is an expected death or not, loss of a family member or friend is difficult to those that are left behind The initial patient is no longer the patient and the needs and care need to be transitioned to those left behind Cultural vs. Educational Deficiency/Differences? Where do we have difficulties? Why do we have difficulties? Confidence? Interpersonal skills? How can we improve?
A great place to start back home Death in the Field: Teaching Paramedics to Deliver Effective Death Notifications Using the Education Intervention GRIEV_ING. Cherri Hobgood, MD, Dana Mathew, MD, Donald J. Woodyard, Frances S. Shofer, PhD, Jane H. Brice, MD, MPH. Prehospital Emergency Care, 2013; 17-501-510 Evaluated veteran providers and ability to provide notification of death to family members Identified areas of deficiency and educational format of GRIEV_ING mnemonic to guide in notifications
Study Findings Evaluated providers on three levels: Confidence Competency Communication Educated providers to essential criteria in delivery of notifications and reevaluated providers Identified specific aspects of interaction necessary
Foundations of Interaction Incorporate and gather all family members present prior to notification Identify and introduce yourself Know who you are speaking with spouse/parent/child should be present Always do the notification with someone else (doesn t have to be an EMS provider, for example, a law enforcement officer might be incorporated in the notification process) If possible, do it in a private place, with the family sitting down
Making the Notification Be direct and explain that has died in spite of your best efforts Use the word died or dead Tell the family what you know about the patient s condition and what actions were taken during the resuscitation, but don t speculate Listen carefully and answer questions from the family When possible, get at or below their eye level Touching is okay, especially if initiated by a family member (i.e. a hand on the shoulder/knee or a hug) Discuss what will happen next Offer to assist in contacting appropriate p resources such as clergy
What Will Happen Next? In most TOR situations, law enforcement will notify the ME/Coroner and stay with the body until the ME arrives. The ME will either transport the body or leave the body for private arrangements to be made by the family. In situations where the ME is coming to the scene, the body should be disturbed as little as possible after resuscitation efforts. In a case where the ME is not coming to the scene or In a case where the ME is not coming to the scene or leaves without taking the body, the family must make their own arrangements with a funeral home.
Typical Family Reactions Crying, anger, hostility, sobbing, blaming Nothing, blank stare, numbness or collapsing Disbelief or denial Guilt Praying Hysteria Fear
Helpful Phrases I am sorry for your loss How can I help? It is normal for you to react this way It is harder than most people think I know this is painful/hard to accept
Unhelpful Phrases You shouldn t feel that way At least. or You re lucky that I know how you feel, my died d recently You have to focus on the good memories At least he/she died in his/her sleep He/she is in a better place now
EMS is really good at this In 2002, a study was done by URMC of 33 asystolic, prehospital cardiac arrest cases, of which 21 underwent TOR by EMS. The family members of all 21 patients were satisfied with both the medical care and emotional support provided by EMS. Edwardsen EA, Chiumento S, Davis E. Family perspective of medical care and grief support after field termination by emergency medical services personnel. Prehospital Emergency Care. 2002 Oct-Dec;6(4):440-4.
Making the call.. HOW AND WHEN IS THIS DECISION MADE?
Terminating Efforts Communication between providers and family is key throughout resuscitative efforts Establish a dialogue between providers throughout efforts and initiate discussion with family early on Same principles of death notifications can be applied to discussion of termination with the family
Termination Discussion will be difficult Family members will express a variety of emotions Educate the family What have you done What are you doing What does this mean Sometimes families have false sense of hope that the hospital can do more
Termination Discuss with family sooner than later, apply the same techniques as during death notifications Involve medical control if there are any Involve medical control if there are any questions, concerns or issues
Take Home Message Cardiac arrest is won on the scene Cardiac arrest can safely be treated and secured on the scene We should train to stop resuscitation rather than transport cardiac arrest patients
But what does the word patient mean? Taken from the Latin, patior, one who suffers
Medicine is designed around diseases Medicine is designed around diseases, not people BJ Miller
What about patients who want to die at home, with dignity and without preventative intervention? What about patients who wish to allow a natural ldeath?
Atul Gawande Being Mortal We have come to medicalize aging, frailty, and death, treating them as if they were just one more clinical problem to overcome. However, it is not only medicine that is needed in one s declining years but life a life with meaning, a life as rich and full as possible under the circumstances Oliver Sacks
How we die is something we can correct our role is to relieve suffering BJ Miller
MOLST or POLST or DNR Documents direct resuscitative efforts and course of hospital treatment Awareness of documents and limitations is key
Introduction to the Medical Orders for Life Sustaining Treatment MOLST Form is physician s order sheet Completed with the patient or patient s designee and physician Provide explicit direction for CPR, mechanical ventilation, and other life sustaining treatments Reviewed with patient t on a regular basis The form is the result of a lengthy discussion with the patient MOLST for EMS & First Responders, July 2010 54
Forms of interest MOLST - definitive orders Patient signature(or proxy) Witness signature MD signature Date (No expiration of authorization) Non Hospital DNR Less options CPR or DNR Either order can at any time be nullified Patient Family MD
Healthcare Proxy Legal documenting assigning g an individual as decision maker on behalf of patients. Valid when individual is no longer capable of making end of life decisions or guiding current treatment Effectiveness requires individual named as proxy to have an understanding of patient s wishes Unlike MOLST, document identifies agent, but not direction of intended care.
If there is a state of the art of end of life care it is this; death with dignity Ken Murray MD from How Doctors Die
Living Will No standardization of Living Will form Court determined that a document is valid if provides clear and convincing evidence of patient s requests S f h l h i i Statement of health care interventions you may or may not want
Dr. Miller said: we should redesign and rethink how people die No profession in medicine is in a better position than EMS to assure that care is delivered with compassion and with the wishes of the patient foremost in our minds
Acknowledgements No financial or academic conflicts of interest Thank you to: Patricia Bomba, MD FACP Medical Director Geriatrics Excellus Chair, Statewide MOLST Implementation Program NYS DOH Jeremy Cushman, MD, MS, EMT-P P, FACEP, Regional EMS Medical Director, MLREMS BJ Miller, MD Atul Gawande, MD David Leisten, BA, CCEMT-P, CIC Erik Rathfelder, MS, BA, EMT-P
Thoughts Talk about your own mortality Teach about your own mortality Watch z-dogg md with your colleagues, resident and spouse Be a part of the next phase of resuscitation ti medicine never stop until it is time, but we should be the people who learn when to say enough...
EMS Medicine Live Upcoming EML Tuesday November 24 th Michael Dailey, EMS And End-Of-Life Issues Tuesday December 22 nd Kevin Munjal, Mobile Integrated Healthcare