The first time Marjorie Mangiaruca died was on October 10, 2011. She was 90 years old, suffering from significant dementia and living in a skilled nursing facility.
She was found unresponsive with blue lips, gasping for air at Oakbridge Healthcare Center. EMS was called and they quickly began to transport her to the ER. While en route they tried to establish an airway. Before a definitive airway could be established by EMS the patient suffered a cardiac arrest. The ambulance was pulled to the side of the road and CPR was begun and a tracheostomy* was performed. The patient was given medications to “restart her heart” ( I assume epinephrine, but I do not know) and for reasons that are unexplained she was given paralytics by the EMS crew.
Two days later she was removed from ventilator and ultimately passed away in a palliative care unit on October 17th, 2010. 1
The patient did have a DNR order but her DNR status was not conveyed to EMS. Months before the patient had expressed her wishes to her daughter that she would not want to have a prolonged death, or to have her life extended by any artificial means, including any medical intervention to unnaturally delay her death. Her daughter having POA, obtained a correctly filled out state DNR form for her mother but somehow this was not communicated from the SNF to EMS or the ER. EMS did the right thing here, at least in the eyes of the law.
Would you perform a cricothyrotomy on a 90 yearfemale cardiac arrest patient with dementia that resides in a skilled nursing facility regardless of a DNR or nor? Forgetting for a minute that there is a potential for litigation and ignoring antiquated state laws, is it ethical to attempt to resuscitate a 90 year old woman with dementia who resides in a nursing home? Is it right? Is it something that is just?
There isn’t an easy answer here. From a legal standpoint, (using my facebook law degree) it seems their actions were legally correct. If there is no DNR, no advance directives, no communication about the patient’s wishes and no surrogate decision makers present the law seems to lean towards “do everything.”
Ethically though, I have an issue with it. Performing a cricothyrotomy on a 90 year old nursing home patient with dementia just feels wrong to me. While the procedure might be a success, the patient is probably going to die.
If I were to be in the situation that the EMS crew was in I don’t know what I would have done. I want to tell you that I would certainly not do a cricothyrotomy on this patient and when faced with her undergoing a cardiac arrest and a truly a can’t intubate / can’t ventilate scenario that I would make her comfortable, offer palliative care and let her die a peaceful death. Cutting a hole in her neck and paralyzing her (no mention of sedation / analgesia was made either) feels like adding insult to injury to me. It feels unnatural and wrong to me. It feels as though we are robbing a patient of the right to die with dignity.
The elephant in the room is the question of am I imparting my values on others? Is this a case of an EMS provider playing god? Or am I just being a realist here and knowing the expected outcome of this patient type acting accordingly? Would I be risking my license and my career if I let her die peacefully instead of inflicting care on here? I don’t know. Probably.
The case with Majorie is an extreme example of where ethics and law do not always agree.
EMS loves to simplify things making decisions in to either a 1 or a 0. Paranoia runs rampant when EMS speaks about allowing a patient without a DNR to suffer a natural death. I often hear EMS recite the phrase that if there is no DNR a patient will receive all resuscitative measures, because that is what they have to do because of laws, protocols and fear of being sued.
We so often arrive on scene to find a patient in cardiac arrest and ask their family “do they have a DNR?” and the answer is often “I don’t know” or “no”.
The follow up question is usually a variant of “would you like everything done?” or “do you want us to try and resuscitate them?” These are loaded questions; of course people are going to say “yes”. There is an excellent podcast on this from Dr Shreves on this where she explains what we need to be saying.2
We need to find out what is important to the patient and the decision makers regarding end of life care. Not resuscitating a patient does not mean we pack up and leave, it does not mean we abandon the patient and the decision makers. We still take care of the patient, we provide palliative care, we just do not attempt a futile resuscitation.
Family members and surrogate decision makers often are at a loss and do not know what to do when a family member or loved one dies in front of them. They may not know that they have a choice regarding what resuscitative measures are taken, they need to be guided on the process of letting people die, they need to know it is okay; in fact sometimes it is the right thing to allow people to die a natural death. We need to be honest with them that outcomes from resuscitation in the elderly with comorbidities or terminal illnesses are extremely poor and they do not always fall neatly in to dead or alive; there is a terrible gray area where patients are mostly dead, but partly alive, tethered to a ventilator as their organs fail.
We need to inform surrogate decision makers so they can make educated decisions, not simply make decisions. That process starts by educating ourselves. We need to look at the data regarding the survivability of out of hospital cardiac arrest when the patient is in poor health or has significant comorbidities. The 2015 CARES data registry shows survival to discharge with a CPC score of 1 or 2 in nursing home patients that had in a cardiac arrest of presumed cardiac etiology was 1.8%.3
CPR is not a benign treatment. It is violent and often leaves the patient with injuries, some of which are life threatening. One study found that 19.2% of non-traumatic arrests that received CPR had a life-threatening injury, including left ventricle rupture in one patient.4
Should the family ask “what would you do here if you were in my situation?” We must answer them honestly even if the answer is “nothing”.
In 2013 Dr Hayes published a proposed algorithm for discussing resuscitation decisions with families and decision makers.5 This is a model that EMS can adopt and begin using to have these conversations with terminally ill patients, peri-arrest patients and surrogate decision makers for patients.
Other health care providers have taken a step further by introducing an element of paternalistic decision making to this process. “Physicians should recommend against CPR when there is a low likelihood of benefit from CPR and a high likelihood of harm, such as when patients have advanced incurable cancer, advanced dementia, or end-stage liver disease.”6
Is the average EMS provider at a point where they can determine the likelihood of outcomes with regards to CPR well enough to decide who does and does not get resuscitated? Perhaps not and maybe a paternalistic approach is a bit out of the current scope at the paramedic or EMT level. EMS providers should embrace the role of a facilitator to hep guide decision makers through the process and encourage them make an ethically sound decision.
EMS cannot grow up as a profession if we are not willing to take responsibility for our actions and our clinical judgement. It is no longer acceptable for EMS to invoke a defense of “just following orders” when we attempt to resuscitate a futile patient.
*I suspect it was a cricothyrotomy but the report says tracheostomy
References:
1.http://www.thaddeuspope.com/images/Hallada_Complaint_-_FINAL_3.5.13.pdf
2.emcrit.org/podcasts/critical-care-palliation/
4.Umit Kaldırıma, , Mehmet Toygarb, , Kenan Karbeyazc, , , Ibrahim Arzımana, , Salim Kemal Tuncera, , Yusuf Emrah Eyia, , Murat Eroglud. Complications of cardiopulmonary resuscitation in non-traumatic cases and factors affecting complications. Egyptian Journal of Forensic Sciences, 2016; Volume 6, Issue 3, 270–274
5.Hayes B. Clinical model for ethical cardiopulmonary resuscitation decision-making. Internal Medicine Journal. 2013; 43:77-83.
6.Blinderman CD, Krakauer EL, Solomon MZ. Time to Revise the Approach to Determining Cardiopulmonary Resuscitation Status. JAMA. 2012;307(9):917-918. doi:10.1001/jama.2012.236
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The difficulty is you cannot fully explore the ethically ramifications of a resuscitation at the time the patient arrests. You cannot, in that 5 second interval before starting compressions, make an informed assessment of their quality of life or their prospects for recovery. Yes most people in a SNF will not benefit, yes most dementia patients will not benefit; but there are always exceptions. That is a human thing, not an EMS thing.
It is also a bedrock principle of EM that resuscitations have one speed — flat out. When you are trying, you are trying like it was your own child laid out in front of you, not with an effort scaled from one to ten based on age, comorbidities, or place of residence.
Our society has determined, for the time being, that it is up to patients and families to decide whether a life is worth prolonging. That is just not up to us. When they arrive in the emergency department I am going to do my best to give them the full picture and the code status often changes. But in the back of the ambulance with a patient who is full code, that isn’t possible. The crew did rightly.
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Completely agree on the facilitation of good decision making and the paternalistic approach that MDs could take.
I would not answer “nothing” tho. I would say, “let’s do everything to make sure she is comfortable and tested with dignity and respect.”
BTW, you have some typos. 2011 vs 2010.
Thanks
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