The Death of Socrates 

(Portions of this post previously appeared on an EMS facebook group, The EMS Mentoring Society)

Does your agency have protocols for treating and not transporting terminally ill patients?

Scenario: It is 3am early Tuesday morning when you paged to a male party in terrible pain.Mike Sanders is a 56 year old male* with terminal pancreatic cancer. He is gaunt and emaciated, probably weighing 120 lbs at the most; in short, he looks like a terminal cancer patient.

He is lying in a bed, moaning loudly and appears to be in significant pain. His sister tells you that she brought him to her house yesterday because he wishes to pass away in their family home where he grew up. She says he has been battling pancreatic cancer for 6 months and that she expects he has a few days or maybe a week at the most left.

The sister says the pain started last night at 22:00. The patient takes 60mg of oxycodone, 4 times per day (240mg total) and it is not working helping with his current pain.

The family has been in touch with the local hospice agency. There have been some paperwork issues that are getting ironed out between his doctor from where he lived and the local hospice, he is expected to be admitted to hospice in the next 6-12 hours.

The patient appears to be in terrible pain and is nonverbal due to brain tumors from the cancer metastasizing. The family tells you that he will probably die within the next few days and they do not want him to go to the hospital as the patient wished to pass away at the sister’s house.

They ask you if you can please just treat his pain and leave him at home, they feel that there is nothing that can be done for the patient in the ER. You explain that if he were admitted to the hospital they would be able to offer a longer term pain care plan, until the hospice admission is sorted out. The family asks you if you can just treat his pain and not transport.

What will you do?

This is a perfect patient for at-home palliative care measures by EMS. Transporting him to the ER is not what the patient wants (or POA in this case) and the ER can’t do much more than EMS can if the agency has the right protocols.

What is palliative care?
Palliative care focuses on relieving the symptoms of a serious illness. The goal is to reduce pain and other symptoms of a disease and improve quality of life for those with a serious, often terminal illness. Palliative care is not about trying to cure a disease, it is about improving the quality of life for the patient with the time they have left. There are no life-saving heroic measures in palliative care.

Why You Need Palliative Care Protocols:
Sure, you could do a work around where you tell the patient you are going to give them pain medication and then take them to the hospital, but of course they have the right to refuse transport at any time *[wink wink] and all that is needed is a signature from the POA and you will get back in your ambulance and leave. The problem with this approach is it requires a certain willingness to use the loopholes in your protocols to do what is right.
Having palliative care protocols in place lets providers know that not only is the practice of treating terminally ill patients without transport acceptable, it is something your service advocates for.

Other situations that have been encountered where the palliative care protocols are useful are when EMS transports patients with significant pain home from the hospital to in-home hospice care. Knowing it is an acceptable practice to give these patients analgesia and then leave them at home will put many providers at ease. Often times a patient is at home on hospice and they have called the hospice staff but there is a delay in hospice response, so EMS will be called>

When EMS acts as a bridge until hospice can attend the patient we can allow many of these patients to stay at home. This does require somewhat of a paradigm shift from the conventional EMS transport model.

And no, I haven’t figured out how to get paid for these calls by CMS or insurance but they don’t happen all that often and seeing as the patient often will refuse to  go to the hospital anyway the only difference between the refusal and this is a few dollars worth of morphine, and I think this is money well spent. The ROI will be when the family writes your boss or the newspaper about the wonderful care you provided, which is certainly worth more to an EMS agency  than a few dollars. The other return on this investment is knowing that the employees of the agency can operate with a sense of ease when confronted with this situation. Instead of  trying to do the ethical thing while remaining within rigid protocols that state no transport means no drugs, your employees can now be true clinicians and do the right thing without having to have a moral dilemma.

I have attached a copy of our palliative care protocol. Please feel free to use some of it, all of it or none of it. Palliative Care Protocols 

*Information  has been changed to protect patient privacy

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