Therapeutic Communications; Compassion, Death & Dying; MAD Condell Medical Center EMS System October 2010 CE Site Code # 107200-E-1210 Objectives by: Debbie

Therapeutic Therapeutic Communications; Communications;

Compassion, Death & Compassion, Death & Dying; MADDying; MAD

Condell Medical Center EMS SystemCondell Medical Center EMS SystemOctober 2010 CEOctober 2010 CE

Site Code # 107200-E-1210Site Code # 107200-E-1210

Objectives by: Debbie Semenek, RN, EMS System CoordinatorObjectives by: Debbie Semenek, RN, EMS System CoordinatorPacket prepared by: Sharon Hopkins, RN, BSN, EMT-ParamedicPacket prepared by: Sharon Hopkins, RN, BSN, EMT-Paramedic

ObjectivesObjectives Upon successful completion of this module, the EMS Upon successful completion of this module, the EMS

provider will be able to:provider will be able to:

1. Define the communication process.1. Define the communication process. 2. List components of the communication process.2. List components of the communication process. 3. List obstructions to the communication process.3. List obstructions to the communication process. 4. Identify strategies for developing trust and4. Identify strategies for developing trust and rapport with patients.rapport with patients. 5. Define interpersonal zones.5. Define interpersonal zones. 6. Identify strategies used during the interview6. Identify strategies used during the interview process with patients.process with patients.

Objectives cont’dObjectives cont’d

7. Describe elements of patient caring.7. Describe elements of patient caring. 8. Describe the unique challenges for EMS8. Describe the unique challenges for EMS personnel in dealing with themselves, adults,personnel in dealing with themselves, adults, children and special populations related to deathchildren and special populations related to death and dying.and dying. 9. List the 5 predictable stages of loss by9. List the 5 predictable stages of loss by Elizabeth Kubler Ross.Elizabeth Kubler Ross. 10. State the components of the State of Illinois10. State the components of the State of Illinois Advanced Directives.Advanced Directives.

Objectives cont’dObjectives cont’d

11. Review the Region X SOP “Withdrawing11. Review the Region X SOP “Withdrawing Resuscitative Effort”.Resuscitative Effort”. 12. Review the MAD usage.12. Review the MAD usage. 13. Review documentation components for13. Review documentation components for discussed conditions.discussed conditions. 14. Actively participate in case scenario14. Actively participate in case scenario discussions.discussions. 15. Successfully complete the post quiz with a15. Successfully complete the post quiz with a score of 80% or better.score of 80% or better. 16. Given the equipment, demonstrate use of16. Given the equipment, demonstrate use of the MAD device.the MAD device.

CommunicationCommunication

Just an exchange of symbols:Just an exchange of symbols: Written, spoken, gesturedWritten, spoken, gestured

Components of CommunicationComponents of Communication

A A sendersender – creates the message – creates the messageThe The messagemessage is sent is sent

A A receiverreceiver – interprets the – interprets the message sentmessage sentFeedbackFeedback – response is given – response is given to the message receivedto the message received

Failed CommunicationsFailed Communications

Prejudice – toward patient or situationPrejudice – toward patient or situation Lack of empathy – identifying with and Lack of empathy – identifying with and

understanding another’s situation, feelings, understanding another’s situation, feelings, motivesmotives

Lack of privacy – may inhibit responsesLack of privacy – may inhibit responses External distractions – TV, traffic, crowdsExternal distractions – TV, traffic, crowds Internal distractions – thinking about other Internal distractions – thinking about other

thingsthings

Key PointKey Point

Improve communication skills with:Improve communication skills with: PATIENCEPATIENCE

FLEXIBILITYFLEXIBILITY RESPECTFULNESSRESPECTFULNESS

EVIDENCE OF COMPASSIONEVIDENCE OF COMPASSION

Once trust is established, rapport followsOnce trust is established, rapport follows Avoid false promises – they violate your Avoid false promises – they violate your

patient’s trustpatient’s trust

Building Trust & RapportBuilding Trust & Rapport

Use the patient’s nameUse the patient’s name Breaks down some barriersBreaks down some barriers Ask the patient how they want to be addressedAsk the patient how they want to be addressed

To remember names:To remember names: Say the name out loud three times in the 1Say the name out loud three times in the 1stst minute minute ““See” the name in your headSee” the name in your head ““Feel” yourself writing the name in your Feel” yourself writing the name in your

imaginationimagination

Trust and RapportTrust and Rapport

VoiceVoice Watch your volume, speak quietly in low Watch your volume, speak quietly in low

tonestones Check your pitch – high voices are harder to Check your pitch – high voices are harder to

hearhear Watch your rate of speakingWatch your rate of speaking Use a professional, compassionate toneUse a professional, compassionate tone

Avoid sarcasm, irritation, angerAvoid sarcasm, irritation, anger

Trust & RapportTrust & Rapport

ExplanationsExplanations Explain Explain whatwhat you are doing you are doing Explain Explain whywhy you must do something you must do something

Eases patient’s anxietyEases patient’s anxiety

Often best to give a short explanation immediately Often best to give a short explanation immediately prior to the procedureprior to the procedure

Less time for the patient to dwell on what will be Less time for the patient to dwell on what will be donedone

Less time for the imagination to roamLess time for the imagination to roam

Trust & RapportTrust & Rapport Facial expressionsFacial expressions

Keep a kind, calm facial expressionKeep a kind, calm facial expression Keep a “poker” faceKeep a “poker” face

Convinces the patient you can handle the situationConvinces the patient you can handle the situation Smiling when speaking puts a more pleasant tone Smiling when speaking puts a more pleasant tone

in your voicein your voice

Interpersonal ZonesInterpersonal Zones Intimate zone – 0 – 1.5 feetIntimate zone – 0 – 1.5 feet

Visual distortionsVisual distortions Best for assessing breath & body odorsBest for assessing breath & body odors

Personal space – 1.5 – 4 feetPersonal space – 1.5 – 4 feet Used for much of patient interview and assessmentUsed for much of patient interview and assessment No visual distortionNo visual distortion Voice is moderateVoice is moderate

Social distance – 4 – 12 feetSocial distance – 4 – 12 feet Impersonal business transactionsImpersonal business transactions Personal interview in dangerous situationsPersonal interview in dangerous situations

Interviewing TechniquesInterviewing Techniques

Goal:Goal: Identify chief complaintIdentify chief complaint Determine circumstances causing the emergencyDetermine circumstances causing the emergency Determine the patient’s conditionDetermine the patient’s condition

Achieving the goal:Achieving the goal: Asking questionsAsking questions Observational skillsObservational skills Effective listening skillsEffective listening skills


Open-ended questionsOpen-ended questions Questions that permit unguided, spontaneous Questions that permit unguided, spontaneous

answersanswers ““What happened that you needed to call 911?”What happened that you needed to call 911?” ““What seems to be the problem?” What seems to be the problem?”

BenefitBenefit Patient responds in an unguided wayPatient responds in an unguided way May include information that indicates additional May include information that indicates additional

assessment of patient assessment of patient Chief complaint can drive direction of rest of the Chief complaint can drive direction of rest of the

interviewinterview


Leading questionsLeading questions Question framed to guide the direction of Question framed to guide the direction of

the patient’s answerthe patient’s answer ““Are you having chest pain?”Are you having chest pain?”

Problem – Problem – Could miss a serious problem by Could miss a serious problem by

refocusing the patient away from their refocusing the patient away from their true chief complainttrue chief complaint


Direct or closed questionsDirect or closed questions Requests specific informationRequests specific information

““Are you nauseated?”Are you nauseated?” Answers fill in information generated from Answers fill in information generated from

open-ended questionsopen-ended questions Answers crucial questions when time is Answers crucial questions when time is

limitedlimited Helps control overly talkative patientsHelps control overly talkative patients


Ask one question at a timeAsk one question at a time Allows patient to finish answering one question Allows patient to finish answering one question

and to complete their thoughtand to complete their thought Designate one person to ask questionsDesignate one person to ask questions

Confuses patient when multiple people ask Confuses patient when multiple people ask questionsquestions

May not be clear which person/which question May not be clear which person/which question the patient is responding tothe patient is responding to

Listen to the responsesListen to the responses Do not interruptDo not interrupt


Use of languageUse of language Use words the patient understandsUse words the patient understands

““pee” instead of “urinate”pee” instead of “urinate” Avoid slang or jargonAvoid slang or jargon May need to phrase the words multiple ways for May need to phrase the words multiple ways for

the patient to understand the questionthe patient to understand the question Remember that children are literal, concrete Remember that children are literal, concrete

mindedminded You say “I’m taking your blood pressure” and You say “I’m taking your blood pressure” and

the child wonders where you are taking it tothe child wonders where you are taking it to

Patient CaringPatient Caring

“People will seldom remember what you did or what you said. But they will almost always remember how you made them feel.”

Cab Driver, Boston

What EMS does…What EMS does…

We fix problemsWe fix problems Technical stuffTechnical stuff

SplintSplintBandageBandageIV’sIV’sDrugsDrugsEtc.Etc.

What else we do….What else we do….

We fix peopleWe fix people Family concernsFamily concerns Non-medical needsNon-medical needs EmotionsEmotions ComfortComfort Being a friend / advocateBeing a friend / advocate

EM“SEM“S””

SServiceervice Must have a natural ability to like peopleMust have a natural ability to like people

We encounter people at their worst – they are in We encounter people at their worst – they are in crisiscrisis

If you don’t want to be there and you don’t want to If you don’t want to be there and you don’t want to take care of them…they will sense that, so…take care of them…they will sense that, so…

…consider a different profession!

Remember, an emergency is defined by its Remember, an emergency is defined by its owner – owner – notnot by us by us

Don’t underestimate the patientDon’t underestimate the patient People are easily overwhelmedPeople are easily overwhelmed

They don’t know where to They don’t know where to turn, so they turn to usturn, so they turn to us

It does not make them stupidIt does not make them stupid It is not a waste of our time…It is not a waste of our time…

Who Do We Serve?Who Do We Serve?

Define who all of our customers areDefine who all of our customers are In-house, department membersIn-house, department members Vendors supplying the departmentVendors supplying the department Other village/city/governmental departmentsOther village/city/governmental departments Hospital staffHospital staff Our patientsOur patients Our patient’s familiesOur patient’s families Who else???Who else???

What’s the message???What’s the message???

Regard Regard everyoneeveryone as a as a customer.customer.

Be EffectiveBe Effective To be effective with your technical skills you To be effective with your technical skills you

must:must:

See the patient as more than the problem, See the patient as more than the problem, complaint, that they presentcomplaint, that they present

They are customers that reach out to you in the They are customers that reach out to you in the worst moment of their livesworst moment of their lives

Be EffectiveBe Effective

Explain every phase of treatment to your patientExplain every phase of treatment to your patient

Let them know what to expectLet them know what to expect Ask permission before a procedureAsk permission before a procedure

When you can accept a ‘yes’ or ‘no’ answerWhen you can accept a ‘yes’ or ‘no’ answer When there shouldn’t be a choice (ie: necessary When there shouldn’t be a choice (ie: necessary

IV), avoid phrases like “Can I start this IV”IV), avoid phrases like “Can I start this IV” Give the choice, instead, possibly to the IV siteGive the choice, instead, possibly to the IV site

Give them an opportunity to report changesGive them an opportunity to report changes

Patients are highly aware of a caregiver’s attitude – whether positive or negative.

If you show honest concern, the patient will sense it.

Caring…Caring… We must be people who can enjoy serving We must be people who can enjoy serving

others for 30 years and sell them the real dealothers for 30 years and sell them the real deal Not every call is dramaticNot every call is dramatic Burnout is a possibilityBurnout is a possibility

What are your expectations?What are your expectations? Our role in a patient’s life is more than just a Our role in a patient’s life is more than just a

momentmoment

Caring…Caring… Habitually use peoples’ namesHabitually use peoples’ names

Hi. What is your name?Hi. What is your name? Introduce yourselfIntroduce yourself Ask how the patient wants to be addressedAsk how the patient wants to be addressed

Connect with the person – not the problemConnect with the person – not the problem SmileSmile Be respectfulBe respectful Maintain eye contactMaintain eye contact

Immediately puts you in touch with their Immediately puts you in touch with their emotional state and mental statusemotional state and mental status

Caring…Caring…

Remember people have families / significant Remember people have families / significant othersothers Families are important to usFamilies are important to us

HealingHealing InformativeInformative SupportiveSupportive

DO NOT toss a family member/significant others DO NOT toss a family member/significant others aside so we can do our workaside so we can do our work

May be the last time the patient is seen in a May be the last time the patient is seen in a comfortable settingcomfortable setting

Understand that physical comfort, fear and Understand that physical comfort, fear and embarrassment are important to our patientembarrassment are important to our patient Need to be vigorously addressedNeed to be vigorously addressed

Pain controlPain control Keeping a patient warm / coolKeeping a patient warm / cool Providing emotional comfortProviding emotional comfort Maintaining modesty / dignityMaintaining modesty / dignity

Families and DeathFamilies and Death

The reality of death is: The reality of death is: It’s traumaticIt’s traumatic It’s stressful It’s stressful

For us, tooFor us, too It’s a situation that is permanently imprintedIt’s a situation that is permanently imprinted

Everything that is heard and seen and will Everything that is heard and seen and will be rememberedbe remembered

Delivering the News of DeathDelivering the News of Death

EMS often in the position to have to deliver EMS often in the position to have to deliver news of a deathnews of a death

No script can cover all situationsNo script can cover all situations Each scene must be assessed as well as the Each scene must be assessed as well as the

persons involvedpersons involved Then determine safest and most compassionate Then determine safest and most compassionate

way to deliver sad newsway to deliver sad news Provide a private area for sharing informationProvide a private area for sharing information

Deaths – Phrases to avoid…Deaths – Phrases to avoid…

““I know how you feel”I know how you feel” ““I understand”I understand” ““You’re so strong”You’re so strong” ““Get on with your life”Get on with your life” ““It was God’s will”It was God’s will” ““They led a good life”They led a good life” ““It could have been worse”It could have been worse”

The high roadThe high road CompassionateCompassionate

To each otherTo each other Conveying caring / offering condolencesConveying caring / offering condolences

Explaining actions / inactionsExplaining actions / inactions Giving permission to grieveGiving permission to grieve

Denial, anger, bargaining, depression, acceptance Denial, anger, bargaining, depression, acceptance Offering continuing supportOffering continuing support

ClergyClergy CISM (CISD # 1-800-225-2473)CISM (CISD # 1-800-225-2473) CounselorsCounselors FriendsFriends

Caring…Caring…Two roads to takeTwo roads to take

The low road…The low road…

Tough / abrasiveTough / abrasive Don’t talk to anyone, keeping them awayDon’t talk to anyone, keeping them away ““Death does not phase me” attitudeDeath does not phase me” attitude Being coldBeing cold Being distantBeing distant

Tough is Tough is notnot professional professional

Dealing with the difficult situationDealing with the difficult situation Families who are able to spend time with Families who are able to spend time with

the body or dying person do better the body or dying person do better emotionally in the long runemotionally in the long run““There is an image of the loved one looking There is an image of the loved one looking

worse than they really are when the body can’t worse than they really are when the body can’t be seen.”be seen.”

If the image is bad, give family the optionIf the image is bad, give family the option

What to say & do…What to say & do…

It’s OK to share that it’s hard for youIt’s OK to share that it’s hard for you Let touch convey caringLet touch convey caring ““I wish so much you had them back”I wish so much you had them back” ““I see how painful this is for you”I see how painful this is for you” Ask to hear about their loved oneAsk to hear about their loved one

Be a good listenerBe a good listener

Stages of LossStages of Loss

Experienced in any lossExperienced in any loss DeathDeath RelationshipsRelationships JobsJobs

EMS is exposed to a multitude of emotional EMS is exposed to a multitude of emotional responsesresponses We don’t always see people at their best is why we We don’t always see people at their best is why we

always need to function at always need to function at ourour best best

Stages of LossStages of Loss

5 predictable stages5 predictable stages Denial – “not me”Denial – “not me” Anger – “why me”Anger – “why me” Bargaining – “okay, but first”Bargaining – “okay, but first” Depression – “okay, but I haven’t”Depression – “okay, but I haven’t” Acceptance – “okay, I’m not afraid”Acceptance – “okay, I’m not afraid”

Stages can progress in any order and time Stages can progress in any order and time frame for each is individualizedframe for each is individualized

DenialDenial

Inability or refusal to believe the reality of the eventInability or refusal to believe the reality of the event Used as a defense mechanismUsed as a defense mechanism

Person can put off dealing with the inevitablePerson can put off dealing with the inevitable If death is discussed, use the terms “dying, died, If death is discussed, use the terms “dying, died,

death, dead”death, dead” Use of “passed on, left us, gone away” can be Use of “passed on, left us, gone away” can be

misinterpretedmisinterpreted Avoid statement’s of “God’s way” or relief of pain Avoid statement’s of “God’s way” or relief of pain

or other subjective assumptionsor other subjective assumptions

AngerAnger

Really a frustration over inability to control Really a frustration over inability to control situationsituation

Anger can be focused on anyone or anything Anger can be focused on anyone or anything in their pathwayin their pathway

Watch for safety issuesWatch for safety issues

BargainingBargaining

Patients may try to “make deals” to put off or Patients may try to “make deals” to put off or change the inevitablechange the inevitable

““I promise to …(go to church, be kinder, donate I promise to …(go to church, be kinder, donate my money…) if…(the diagnosis is wrong, the my money…) if…(the diagnosis is wrong, the disease isn’t so bad, it was mistaken identity)disease isn’t so bad, it was mistaken identity)

DepressionDepression

Patient experiences a variety of feelings Patient experiences a variety of feelings SadnessSadness MourningMourning Retreats into self/private worldRetreats into self/private world May lose interest in self careMay lose interest in self care

Bathing issuesBathing issues Non-compliance with medical careNon-compliance with medical care

AcceptanceAcceptance

Patient may or may not reach this stagePatient may or may not reach this stage May achieve a reasonable level of comfort May achieve a reasonable level of comfort

with situationwith situation Family may need more support at this point in Family may need more support at this point in

timetime

EMS and Patient ResourcesEMS and Patient Resources

Department peersDepartment peers Department chaplainDepartment chaplain Family membersFamily members Religious affiliationReligious affiliation Hospital services patient is connected toHospital services patient is connected to Hospice if patient is enrolledHospice if patient is enrolled Others?Others?

Components of a Valid DNRComponents of a Valid DNR

IDPH Uniform DNR Order form which has not been IDPH Uniform DNR Order form which has not been revokedrevoked

Name of the patientName of the patient Name and signature of the attending physicianName and signature of the attending physician Effective dateEffective date The words “DO NOT RESUSCITATE”The words “DO NOT RESUSCITATE” Evidence of consent:Evidence of consent:

Signature of the patient or their legal guardianSignature of the patient or their legal guardian Signature of durable power of attorney for Health Signature of durable power of attorney for Health

Care AgentCare Agent Signature of surrogate decision makerSignature of surrogate decision maker

State of Illinois DNR FormState of Illinois DNR Form

Did you know?Did you know? Form is acceptable reproduced in any colorForm is acceptable reproduced in any color

Acceptable components must be presentAcceptable components must be present State of Illinois is only State form acceptableState of Illinois is only State form acceptable

If patient presents an out of State form, CPR If patient presents an out of State form, CPR must be initiatedmust be initiated

Call Medical Control ASAP to request Call Medical Control ASAP to request termination of CPR based on presence of out termination of CPR based on presence of out of State DNR formof State DNR form

IDPH DNR FormIDPH DNR Form

Gives an individual the additional freedom to Gives an individual the additional freedom to decide what medical treatment fits his or her decide what medical treatment fits his or her beliefs and wishesbeliefs and wishes

Differentiates between “full cardiopulmonary Differentiates between “full cardiopulmonary arrest” and a “pre-arrest emergency”arrest” and a “pre-arrest emergency”

Pre-arrest EmergencyPre-arrest Emergency When breathing is labored or stopped but the heart is still When breathing is labored or stopped but the heart is still

beatingbeating

2 options to choose from:2 options to choose from: ““Do Attempt Cardiopulmonary Resuscitation”Do Attempt Cardiopulmonary Resuscitation” ““Do Not Attempt Cardiopulmonary Resuscitation”Do Not Attempt Cardiopulmonary Resuscitation”

There is also a space available for an individual to give There is also a space available for an individual to give “other instructions” regarding application of the DNR Order “other instructions” regarding application of the DNR Order under certain circumstances:under certain circumstances: Accidents Accidents SurgerySurgery ChokingChoking

IDPH DNR FormIDPH DNR Form

The order is still considered valid if the back The order is still considered valid if the back of the form has not been completed.of the form has not been completed.

The order can be revokedThe order can be revoked Writing “VOID” in large letters across the front of Writing “VOID” in large letters across the front of

the form revokes the formthe form revokes the form Form can be torn/shredded/destroyedForm can be torn/shredded/destroyed Can be revoked by the individual or their legal Can be revoked by the individual or their legal

representativerepresentative

Durable Power of Attorney for Durable Power of Attorney for Healthcare (DPOA)Healthcare (DPOA)

Written record (multiple pages)Written record (multiple pages) Allows patient to choose an agent who will Allows patient to choose an agent who will

make healthcare treatment decisions when the make healthcare treatment decisions when the patient cannotpatient cannot

Applies whenever the patient Applies whenever the patient can no longercan no longer make treatment decisions for themselvesmake treatment decisions for themselves

Provides “agent” with power to provide Provides “agent” with power to provide consents and refusal for any type of medical consents and refusal for any type of medical care or treatmentcare or treatment

DPOA FormDPOA Form

Completed by any adult with sound mindCompleted by any adult with sound mind Must be witnessedMust be witnessed Agent’s signature is not mandatoryAgent’s signature is not mandatory Can be revoked at any timeCan be revoked at any time Downside for EMSDownside for EMS

Less familiar to EMS than the DNR formLess familiar to EMS than the DNR form Lengthy document to review in critical situationLengthy document to review in critical situation

Living WillLiving Will

Written recordWritten record Expresses care patient would choose during a Expresses care patient would choose during a

terminal injury or illnessterminal injury or illness Specifies care patient would want / not wantSpecifies care patient would want / not want Cannot be used if the patient is capable of Cannot be used if the patient is capable of

making decisionsmaking decisions Is not recognized by EMSIs not recognized by EMS

If presented by a Living Will document, begin If presented by a Living Will document, begin appropriate care and contact Medical Controlappropriate care and contact Medical Control

Region X SOPRegion X SOPWithdrawing Resuscitative EffortsWithdrawing Resuscitative Efforts

Contact Medical Control

while continuing patient care

⇓Report events of the call including estimated

duration of cardiac arrest

and treatments rendered.

⇓

Reaffirm the following:• Patient is normothermic adult

• Patient experienced an unwitnessed arrest• Advanced airway secured and IV/IO

placement confirmed• Patient remains in arrest despite aggressive

BLS and ALStreatment modalities following appropriate

SOPs• At least two full medication rounds have

been administered⇓

⇓

SOP cont’dSOP cont’d⇓

If the Physician orders termination of efforts,note the time of death and the physician’s name

on the run report.Notify Coroner or Medical Examiner.

NOTE: Only a physician may make the determination to withdraw resuscitative efforts

⇓

Review - MADReview - MAD

MMucosal ucosal aatomization tomization ddeviceevice Tool to deliver medications via nasal routeTool to deliver medications via nasal route

Medication atomized into tiny particlesMedication atomized into tiny particles Nasal mucosa highly vascularNasal mucosa highly vascular

Immediate absorption into bloodstreamImmediate absorption into bloodstream No delay in gaining accessNo delay in gaining access

MADMAD Syringe can be filled as neededSyringe can be filled as needed Tips are removableTips are removable Deliver medication in divided dosesDeliver medication in divided doses

Maximum of 1 ml per naresMaximum of 1 ml per nares

MADMAD

Insert device into nostril and Insert device into nostril and make firm sealmake firm seal

Hold head steadyHold head steady Aim tip of MAD towards same Aim tip of MAD towards same

side earside ear As quick as possible deliver As quick as possible deliver

medicationmedication Divide dose volume equally Divide dose volume equally

into both nostrilsinto both nostrils Max volume 1 ml per naresMax volume 1 ml per nares

Documentation MADDocumentation MAD

Document in the usual manner for medication Document in the usual manner for medication administrationadministration

Dose route indicated is “inh”Dose route indicated is “inh”

Example:Example: 1020 - Narcan - 2mg - inh1020 - Narcan - 2mg - inh

Include response to intervention in commentsInclude response to intervention in comments

Case Scenario #1Case Scenario #1

EMS is called to a location for a person with EMS is called to a location for a person with shortness of breathshortness of breath

Upon arrivalUpon arrival Patient conscious, in respiratory distress laying in Patient conscious, in respiratory distress laying in

a hospital beda hospital bed History lung cancer, in hospiceHistory lung cancer, in hospice

Family states the patient has a valid DNR and Family states the patient has a valid DNR and produces formproduces form

Family requests transport but no other careFamily requests transport but no other care

What are you going to do?What are you going to do?

Discussion Case Scenario #1Discussion Case Scenario #1

1. Who speaks for the patient at this time?1. Who speaks for the patient at this time? Patient is consciousPatient is conscious Patient has a valid DNRPatient has a valid DNR Patient speaks for themselvesPatient speaks for themselves

2. Is it appropriate to withhold care because 2. Is it appropriate to withhold care because the patient is in hospice?the patient is in hospice? What is the purpose of the DNR?What is the purpose of the DNR? When does the DNR become “active”? When does the DNR become “active”?

REMEMBER…REMEMBER…

DNR meansDNR means ““Do Not Resurrect”Do Not Resurrect”

Doesn’t mean “Do Not Treat”Doesn’t mean “Do Not Treat” Provide care based on signs, symptoms and Provide care based on signs, symptoms and

general impressiongeneral impression Provide oxygenation, pain control, medication, etcProvide oxygenation, pain control, medication, etc

If it were your family member, how would you If it were your family member, how would you want them to be treated?want them to be treated?


EMS arrives on the scene and the patient is EMS arrives on the scene and the patient is triple 0 (0-0-0)triple 0 (0-0-0) No evidence of foul play or traumaNo evidence of foul play or trauma

The patient was found by the family just prior The patient was found by the family just prior to the callto the call

The family states the patient has a DNR; the The family states the patient has a DNR; the patient would not want to be “worked”patient would not want to be “worked”

Discussion Case Scenario #2Discussion Case Scenario #2 What should be your first approach at the scene?What should be your first approach at the scene?

Assess the patient (ABC’s)Assess the patient (ABC’s) Request to see the DNR formRequest to see the DNR form

If the DNR is not presented, how do you proceed?If the DNR is not presented, how do you proceed? CPR must be initiated until a valid DNR is producedCPR must be initiated until a valid DNR is produced Once a valid DNR is produced, contact Medical ControlOnce a valid DNR is produced, contact Medical Control

Give reportGive report Be specific and ask for what you wantBe specific and ask for what you want

With the valid DNR form in hand, “can we stop With the valid DNR form in hand, “can we stop CPR?”CPR?”


Once CPR is started, when can EMS stop Once CPR is started, when can EMS stop CPR?CPR? When patient is resuscitatedWhen patient is resuscitated When a physician directs you to stopWhen a physician directs you to stop When there is someone to take overWhen there is someone to take over When you are exhausted and there is no one to When you are exhausted and there is no one to

relieve yourelieve you Document name of physician ordering CPR to Document name of physician ordering CPR to

be stoppedbe stopped Document time CPR was stoppedDocument time CPR was stopped


You are called to the scene for a 27 year-old You are called to the scene for a 27 year-old patient who is unresponsive at workpatient who is unresponsive at work

No history of traumaNo history of trauma Last seen 3 hours agoLast seen 3 hours ago 102/56; P – 86; R – 4; pupils constricted102/56; P – 86; R – 4; pupils constricted AVPU – responds to painful stimuli (purposeful)AVPU – responds to painful stimuli (purposeful) GCS – 2/2/5 – 9GCS – 2/2/5 – 9

Describe further assessment needed and Describe further assessment needed and describe interventions takendescribe interventions taken


Immediate problem is airwayImmediate problem is airway What techniques could be used to open this What techniques could be used to open this

airway?airway? In absence of trauma, head tilt - jaw thrustIn absence of trauma, head tilt - jaw thrust In presence of trauma – modified jaw thrustIn presence of trauma – modified jaw thrust

What interventions could be used to maintain What interventions could be used to maintain an open airway?an open airway? Oropharyngeal in the absence of a gag reflexOropharyngeal in the absence of a gag reflex Nasopharyngeal with or without a gag reflexNasopharyngeal with or without a gag reflex Intubation with conscious sedationIntubation with conscious sedation


How do you address the breathing problem? How do you address the breathing problem? (respiratory rate 4 per minute)(respiratory rate 4 per minute) Maintain an open airwayMaintain an open airway Augment the respiratory rate to ventilate the Augment the respiratory rate to ventilate the

patient once every 5 - 6 seconds (has spontaneous patient once every 5 - 6 seconds (has spontaneous heart beat)heart beat)

Use BVMUse BVM Have suction available and readyHave suction available and ready

Now trouble shoot why the respiratory rate is a Now trouble shoot why the respiratory rate is a problemproblem

Discussion Case Scenario #3Discussion Case Scenario #3 Further assessment detail:Further assessment detail:

Blood sugar level - 86Blood sugar level - 86 EKG monitorEKG monitor

Sinus rhythmSinus rhythm Consider need for 12 lead EKG based on dataConsider need for 12 lead EKG based on data

Patient assessmentPatient assessment Lead II rhythm stripLead II rhythm strip General impressionGeneral impression

Physical assessmentPhysical assessment No signs of traumaNo signs of trauma No evidence of drug paraphernaliaNo evidence of drug paraphernalia


Why does this patient have an altered level of Why does this patient have an altered level of consciousness?consciousness?

Think:Think: A – acidosis, alcoholA – acidosis, alcohol E – EpilepsyE – Epilepsy I – Infection (brain, sepsis)I – Infection (brain, sepsis) O – OverdoseO – Overdose U – Uremia (kidney failure)U – Uremia (kidney failure) T – Trauma, tumor, toxinsT – Trauma, tumor, toxins I – Insulin – hypo or hyperglycemiaI – Insulin – hypo or hyperglycemia P – Psychosis, poisonP – Psychosis, poison S – Stroke, seizureS – Stroke, seizure


Possible drug overdosePossible drug overdose Altered level of consciousnessAltered level of consciousness Pinpoint pupilsPinpoint pupils Depressed respirationsDepressed respirations

InterventionIntervention Support airway (BVM in this case)Support airway (BVM in this case) Administer Narcan Administer Narcan Obtain blood glucose levelObtain blood glucose level Be prepared for vomitingBe prepared for vomiting


NarcanNarcan Narcotic antagonistNarcotic antagonist Dose 2 mg IVP Dose 2 mg IVP Repeated every 5 minutes as needed to achieve Repeated every 5 minutes as needed to achieve

desired effectdesired effect Maximum dose total 10 mgMaximum dose total 10 mg RoutesRoutes

IVP/IOIVP/IO Inhalation (Inh)Inhalation (Inh)


What is maximum volume for each nostril What is maximum volume for each nostril using the MAD?using the MAD? 1 ml1 ml Divide total volume between each nostrilDivide total volume between each nostril

Increases absorption surface areaIncreases absorption surface area What are “desired” effects of Narcan?What are “desired” effects of Narcan?

Improvement in level of consciousnessImprovement in level of consciousness Improvement in ventilation rate and depthImprovement in ventilation rate and depth

NarcanNarcan

Does the patient have to be awake and talking?Does the patient have to be awake and talking? Is that the “desired” effect?Is that the “desired” effect?

NO!!!!NO!!!! For combative patients, why would you For combative patients, why would you

want them totally awake?want them totally awake? Goal is to improve ventilationsGoal is to improve ventilations

Narcan cont’dNarcan cont’d

Remember with narcotics and NarcanRemember with narcotics and Narcan Narcan is short actingNarcan is short acting Once patient improves ventilations, the Once patient improves ventilations, the

narcotic influence may depress ventilations narcotic influence may depress ventilations again when Narcan wears offagain when Narcan wears off


Altered perceptionsAltered perceptions Have one member wear distorted glassesHave one member wear distorted glasses Have second member review the release form or Have second member review the release form or

other document and ask the “patient” to review and other document and ask the “patient” to review and signsign

Discuss as a group the distorted perception Discuss as a group the distorted perception experiencedexperienced


Altered perceptionsAltered perceptions Have one member of the group muffle their Have one member of the group muffle their

hearinghearing Have a second member talk to the “patient” and Have a second member talk to the “patient” and

give the “patient” commands to followgive the “patient” commands to follow Discuss as a group the distorted perception Discuss as a group the distorted perception

experienceexperience

Final Comments….Final Comments….

Consider how and what you are Consider how and what you are doing looks to others.doing looks to others.

……and what and what you say!you say!

Some more to think aboutSome more to think about

Treat all patients with gentlenessTreat all patients with gentleness Provide a smooth rideProvide a smooth ride Always tell the truthAlways tell the truth Count your blessingsCount your blessings

Always be nice – Always be nice – treat everyone with treat everyone with respect, respect,

kindness, kindness, patience, and consideration.patience, and consideration.

BibliographyBibliography

Bledsoe, B., Porter, R., Cherry, R. Paramedic Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. Prentice Hall. Care Principles and Practices. Prentice Hall. 2009.2009.

IDPH Uniform DNR Order Form. PO 335136 IDPH Uniform DNR Order Form. PO 335136 100M. 5/05.100M. 5/05.

Region X SOP, March 2007; amended January Region X SOP, March 2007; amended January 1, 2008.1, 2008.

Steingart, J. Chief, Countryside Fire Protection Steingart, J. Chief, Countryside Fire Protection District. District. Patient CaringPatient Caring. 2010.. 2010.

Documents

Therapeutic Communications; Compassion, Death & Dying; MAD Condell Medical Center EMS System October 2010 CE Site Code # 107200-E-1210 Objectives by: Debbie