As a paramedic, you’ve likely experienced this scenario: You arrive on scene to find a pulseless, non-breathing patient. Someone mentions they’re in hospice care and “don’t want anything done,” but there’s no paperwork visible. What do you do? Start resuscitation? Wait? This ethical and legal dilemma represents one of the most anxiety provoking aspects of prehospital care.
Understanding the Forms
Advanced directives encompass several documents that outline a patient’s medical wishes:
- DNR/DNI Forms: Focus specifically on code status and resuscitation preferences (Do Not Resuscitate/Do Not Intubate). These forms require a physician’s signature after discussions with the patient about their wishes. In most jurisdictions, these forms must be physically present to be honored.
- MOST/POLST Forms: Medical Orders for Scope of Treatment (MOST) or Physician Orders for Life-Sustaining Treatment (POLST) forms provide more comprehensive guidance beyond just code status. These transportable physician orders typically address:
- Code status (DNR/DNI)
- Level of medical intervention (comfort care, limited intervention, full treatment)
- Guidelines about hospitalization
- Nutrition/hydration preferences
- State-Specific Advanced Directives: Legal documents that vary by location
IMPORTANT CLARIFICATION: Not all hospice patients are DNR/DNI. While the vast majority of hospice patients choose to be DNR/DNI, it is not a requirement for hospice enrollment. The primary criterion for hospice is a prognosis of six months or less, regardless of code status.
When the Grey Areas Emerge
The most challenging scenarios typically involve:
1. Missing Documentation
When family or caregivers report a DNR exists but no form is present, protocol typically dictates beginning resuscitation. However, consider:
- Contacting medical direction if the clinical picture strongly suggests end-stage disease
- Asking specific questions about when and how the DNR was established
- Looking for other documentation like medication lists that might support hospice or end stage medical disease
2. Family Wishing to Override Documentation
When legally designated decision-makers want to override existing DNR orders:
- Verify their legal authority to make decisions
- You may have to start resuscitation as legally they can override the DNR but as you do you can continue to discuss with the surrogate decision maker if this is indeed what the patient would have wanted-
- Explore the context in which the original DNR was created
- Discuss the patient’s illness trajectory and quality of life
- Frame the conversation around what the patient would want
3. Facility Staff Uncertainty
When responding to facilities where staff seem uncertain or uncomfortable with the patient despite what the goals of care form states:
- Redirect the conversation to the patient’s wishes rather than facility concerns
- Contact family members when possible
- Consider involving hospice providers if they’re part of the patient’s care team
- Ultimately if the facility is uncomfortable and/or comfort measures cannot be met at the facility you may need to transport to the Emergency Department
Communication Approaches That Work
When faced with these situations, several communication techniques prove effective:
- Explore illness understanding: “What’s your understanding of their medical condition? How has their condition changed in recent weeks/months?” This provides an opportunity to align their understanding with the current reality before discussing interventions.
- Explore the context in which the form was created: Begin by asking questions about how the form came to be- “Can you tell me about when this form was completed? What discussions led to these decisions?”
- Discuss quality of life: “What has their quality of life been like recently? What would a quality day look like for them? When was the last time they had that kind of quality day?”
- Be compassionately direct: “I’m concerned your loved one is dying. What should we focus on if their time is short?”
- Acknowledge emotions: “I can see this is difficult. What worries you most right now? What are you worried might happen?” Family members are often experiencing intense emotions. Naming emotions can help family members process their feelings and potentially align with the documented wishes.
- Offer recommendations based on goals: “Based on what you’ve told me about their wishes, may I recommend a plan? Would it be helpful if I suggested a plan that aligns with their wishes?Based on what you’ve told me about what’s important to your loved one, and what I’m seeing medically, I’d recommend…” Combine your understanding of their goals with your medical expertise.
Balancing Protocol with Compassion
For Critical Situations- when time is limited and a patient appears to be actively dying:
- Be compassionate but direct: “I’m concerned that your loved one is dying. What should we focus on if their time is short?”
- This approach acknowledges reality while centering the conversation on what matters most to the patient.
Remember that protocols exist for a reason. When in doubt, err on the side of resuscitation—but don’t hesitate to contact medical direction. Your medical knowledge combined with good communication skills allows you to:
- Understand what the patient would want
- Recommend a plan that aligns with those wishes
- Support family members through difficult decisions
Protocols provide guardrails, not handcuffs. They help reduce the emotional burden when decisions are unclear while allowing room for clinical judgment when the situation becomes clearer.
When Documentation is Absent
When responding to a scene where family reports a patient is DNR/DNI but no documentation is present:
- Gather as much information as possible about the patient’s condition and wishes
- Consider the entire clinical picture, including evidence of terminal illness
- Contact medical direction for guidance
- If resuscitation is initiated, continue reassessing its appropriateness
- Document all decision-making processes thoroughly
Remember that protocols exist for a reason. When in doubt, err on the side of resuscitation—but don’t hesitate to contact medical direction. Your medical knowledge combined with good communication skills allows you to:
- Understand what the patient would want
- Recommend a plan that aligns with those wishes
- Support family members through difficult decisions
Protocols provide guardrails, not handcuffs. They help reduce the emotional burden when decisions are unclear while allowing room for clinical judgment when the situation becomes clearer.
The Palliative Care Distinction
It’s important to understand that palliative care and hospice are not synonymous:
- Palliative Care: Focuses on improving quality of life for patients with serious illness at any stage, even those receiving curative treatment
- Hospice: End-of-life care for patients with a prognosis of six months or less who are no longer pursuing curative treatment
As an EMS provider, you may encounter patients anywhere along this spectrum. Your ability to provide symptom management can be invaluable, particularly when hospice providers cannot respond immediately to symptom crises.
Medication Management: Bridging the Gap
Many 911 calls for hospice patients occur because symptoms cannot be adequately managed with the patient’s available oral medications. In these situations, EMS providers can serve as a critical bridge by providing parenteral medications until the hospice nurse arrives or the patient regains the ability to take oral medications.
Common Symptoms Requiring Intervention:
- Pain Management:
- IV opioids can provide rapid relief when oral medications are insufficient
- Consider reduced dosing in opioid-naïve patients while recognizing that hospice patients may have significant opioid tolerance
- Titrate to comfort while monitoring respiratory status, especially in end-of-life care where comfort is the priority
- Nausea/Vomiting:
- Ondansetron (Zofran) IV/IM for general nausea
- Haloperidol (Haldol) for opioid-induced nausea or refractory cases (commonly used in hospice care)
- Promethazine or metoclopramide per protocol and medical direction
- Dyspnea:
- Low-dose opioids can effectively manage air hunger and breathlessness
- Consider benzodiazepines for associated anxiety per medical direction
- Positioning and oxygen for comfort (regardless of saturation)
- Acute Anxiety/Agitation:
- Benzodiazepines may be appropriate with medical direction
- Gentle verbal reassurance and presence often invaluable
Treat in Place Approach:
When symptoms can be effectively managed on scene, the most appropriate intervention may be to:
- Provide parenteral medications for symptom control
- Contact medical direction for guidance on dosing and treatment plan
- Coordinate with the responding hospice nurse
- Document a patient refusal after symptoms are controlled
- Ensure clear handoff to hospice staff or family caregivers
This approach respects the patient’s wishes to remain at home while providing necessary symptom relief. Always work within your agency’s protocols and with online medical direction to ensure appropriate documentation and decision-making support.
Balancing Professional Judgement with Protocol
These situations require balancing clinical judgment with protocol adherence. Be mindful of:
- Your own biases about futility of care
- The family’s comfort level with making end-of-life decisions in the home setting
- The values of the patient as expressed in documentation or by surrogate decision-makers
Remember that transporting a patient to the hospital despite documented wishes is sometimes appropriate when symptoms cannot be managed in the home or when family members need additional support in decision-making.
Resources for Further Learning
For paramedics interested in developing these skills further:
- Center to Advance Palliative Care (CAPC): Offers educational modules on communication skills and symptom management
- VitalTalk: Provides training in serious illness communication
- National POLST: Information about POLST/MOST forms by state
- Hospice & Palliative Nurses Association: Resources for clinical practice
- Check your state and local EMS protocols for palliative care guidance
Remember that these challenging scenarios represent opportunities to provide truly patient-centered care at life’s most vulnerable moments. By combining your medical expertise with thoughtful communication, you can help ensure patients’ wishes are honored while supporting families through difficult transitions.
This blog/podcast is intended for educational purposes only and should be used in conjunction with your agency’s protocols and medical direction.