We were forced to choose between being humane and following policy. The elderly gentleman performed a long, slow agonal respiration as we burst into his room in the back of the house. But as we whipped out our tubes and defibrillator, his daughter stopped us. He did not have a signed DRN form, she said, but he’d been sick for a long time and wanted to die at home; she’d called only for support during his last moments.
We paused. We did not start CPR. We watched. There were no more respirations. After a few minutes, we applied the monitor to confirm death.
Policy at the time demanded we resuscitate when there were signs of life and no signed DNR. So I did what others have done: I dishonestly wrote my report to match the policy.
Over the past three years, the Los Angles County EMS system, along with UCLA, has been studying a new policy that allows Los Angeles County paramedics to forgo resuscitation in situations without a signed DNR document when a family member on the scene verbally requests no resuscitation in accordance with the patient’s wishes, or in patients with asystole who have been down for 10 minutes or more without CPR. (See “Forgoing Resuscitation” on page 4 of this issue.) The policy allows L.A. to join cities such as Seattle and Toronto in addressing long-held EMS policies that make resuscitation unavoidable and automatic for all arrested patients without DNRs or overt signs of death.
Over dinner recently, L.A. County’s EMS medical director, Bill Koenig, told me that the policy change has been enthusiastically welcomed by paramedics, who needed a way to humanely address death and family wishes in the out-of-hospital arena. He said that since the policy has been in place, there has not been a single reported negative consequence to its implementation. There have been no reports of either negligence by paramedics or emotional harm to family members attributed to the new policy. What’s more, a study of the policy shows a small but meaningful reduction in attempted resuscitations.
However, the most interesting finding of the study is the significant decrease in reported signs of irreversible death following implementation of the policy. According to the California HealthCare Foundation, the magnitude of this decrease suggests that the new policy has changed how paramedics document clinical findings. In the past, they may have followed family wishes and decided to forgo resuscitation and then—falsely—documented the circumstances as irreversible death (as I did in the case mentioned above). Instead of being dishonest on the patient care report to protect their humane actions, paramedics can now document more accurately and honestly. The Foundation suggests this could be a boon to job satisfaction and help to mitigate burnout.
At times the best practice is not the one led by medical science or by the fear of litigation but by sensible practice in the field. Twenty years ago, paramedics were talking about the need for policies that would allow them more latitude in difficult field resuscitation decisions because they knew empirically that resuscitation for all was not a best practice.
The lesson here is far-reaching: Pay close attention to discrepancies between policy and practice; if practice is consistently at odds with policy, consider a close examination of policy. The practice may be more sensible and indeed the best practice.
John Becknell is the founding publisher of Best Practices. You can reach him at jmbecknell@gmail.com.
