Managing death with dignity
As EMTs, we sometimes have the privilege and responsibility of helping people die
Sunday was World AIDS Day. For a moment in time, people around the globe paused to remember both strangers and loved ones who have succumbed to the disease, or are living with it today. Younger EMS providers may not recall the early effect of the disease in their community, but there is relevance in how we manage death in the field today.
In the early ‘90s I was a medic working in San Francisco with the health department's EMS division. It was a daily, often multiple occurrence to respond to a home where death from AIDS had happened. Protocols at that time required us to work up cardiac arrests in nearly all circumstances where obvious signs of irreversible death were not evident. So we did what we had to do — break protocol and "withhold resuscitative efforts," since we didn't pronounce death. It was the right thing to do, and everyone did it. Eventually do not resuscitate orders were implemented statewide and provided us the ability to greet death with dignity.
The act of dying is the final period of a life story. The story may be long or short, joyful or tragic. But death is universal. EMS providers see it often.
For a long time we endeavored to reverse it; it was life at any cost. But at what point does the cost outweigh the benefit? Modern medicine (and occasionally inaccurate television shows) has made us believe that cheating death is always an option. We know better. As the journal Circulation put it, “Current CPR strategies are effective in the initial 15 minutes, and after that they are unproductive and often futile.” So the next best thing we can do is to dignify death by greeting it with respect and care. It won't always be that our clinical skills save the day — but our empathy and professionalism will be what the survivors remember long after the event recedes into a distant memory.
It's with a bit of irony that EMS began as an offshoot of the local funeral home in many parts of the country; we end up bringing the skills of a mortician to the patient's side in such circumstances.
If you are working in an area where transporting cardiac arrests is routine — don't take this the wrong way, but please stop. It doesn't help with the grieving process, it won't change clinical outcomes, and you put yourself and others at risk during transport. Moreover, it's not the right thing to do. We are in the profession of doing the Right Thing; when death occurs, withholding resuscitation may be the right medicine.