Rapid Response: Medics’ suspension for stopping CPR a byproduct of bad situation
Lack of training, confusing policy, and bystander conflict make halting or continuing resuscitation nearly impossible for medics to do what's right
What happened: Six Maplewood (Minn.) Fire Department medics were put on leave and subject to investigation after halting resuscitation on a 71-year-old woman at the request of her husband, who was also the power of attorney. The woman was reported to be suffering from Parkinson's disease and in poor health.
News reports don’t make it clear whether a valid, written DNR order was presented. One news source reported Maplewood FD policy regarding such incidents reads accordingly: "Until properly completed orders are presented, pre-hospital personnel will assume that no valid DNR orders exist and proceed with standing orders for resuscitation as medically indicated."
Why it’s significant: This type of incident – medics receiving conflicting instructions regarding end-of-life care – is hardly unique. Medics are inadequately trained on when to withhold care, receive conflicting requests, and are far too often left to interpret or investigate the patient's wishes while also being pressured by bystanders to provide care. Families and other health care providers are as equally or even more poorly prepared for these inevitable situations.
Top takeaways: There was little room for the medics to get this situation 100 percent correct. 911 was activated even though a power of attorney didn't want advanced life support to be provided. The power of attorney was not present and presumably didn't communicate his wishes to his son or the staff responsible for the patient's care.
When the medics stopped resuscitation, seemingly the best choice given the power of attorney's request, they were put on leave and investigated. How the police came to investigate – finding no criminal wrongdoing – or who made a complaint remains unclear. Meanwhile, a family that should be mourning the loss of a spouse and mother finds itself in the media and medics who should be serving the community are off the job.
Again, this incident is not unique. Many medics will find or have found themselves in a very similar situation. These are my top takeaways:
- Medical control. Involve online medical direction if there is any doubt or conflict about appropriate end of life care.
- On scene supervisor. Support medics with a field supervisor, battalion chief or other senior leader on every cardiac arrest call. If resuscitation is ongoing the role of a 'code commander' is critical. If resuscitation is halted, adherence to protocol and policy is equally critical.
- Education. More and regular training needs to be provided to medics, families and other health care providers. Table top this exact situation with the staff at the skilled nursing and long-term facilities in your community.
- Public education. Constantly educate the public about end-of-life planning and how to avoid situations like this.
What’s next: In my opinion, the next logical step for the Maplewood incident is to clear these medics of any wrongdoing, acknowledge their ethical stance to honor the wishes of the power of attorney, and return them to duty as quickly as possible. Meanwhile, EMS leaders, educators and medical directors can learn from this incident to better prepare their providers for the inevitable similar encounter they will have.
What do you think should happen next for this specific incident and at your service?
- Research explores EMS providers' role in end-of-life calls
- Termination of resuscitation: When to say "when"
- Pediatric traumatic arrest: When to withhold or terminate resuscitation
- Duty to act, assess, treat and transport: A legal refresher for EMS providers
- What we can learn about documentation and duty from Michael Jackson