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 (Do Not Resuscitate/Do Not Intubate)
- MOST/POLST Forms: Provide broader guidance beyond code status, including treatment preferences
- State-Specific Advanced Directives: Legal documents that vary by location
A key misconception worth addressing: not all hospice patients automatically have DNR orders. While most do choose this option eventually, enrollment in hospice care does not require a DNR. This distinction is important when responding to hospice patients.
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?”
- 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?”
- Offer recommendations based on goals: “Based on what you’ve told me about their wishes, may I recommend a plan?”
Balancing Protocol with Compassion
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.
Symptom Management: The Overlooked Option
Sometimes families call 911 not because they want resuscitation, but because they’re struggling with symptom control. Your intervention might best serve the patient through:
- Pain management
- Treatment of dyspnea
- Anti-nausea medications
- Helping stabilize symptoms until hospice providers arrive
Resources for Further Learning
For paramedics interested in developing these skills further:
- Check your state and local EMS protocols for palliative care guidance
- Explore resources from the Center to Advance Palliative Care (CAPC.org)
- Consider training in serious illness communication through programs like Vital Talk
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.