Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 13

I got a call to go see one of my HH patients, who I am very familar with, because the family reported that her/his 02 sats were hanging in the 70's all day and even though she/he was not SOB they... Read More

  1. by   cardiacRN2006
    Quote from lizz
    Well, that was my other question. Does the patient forfeit rights to refuse treatment after they call 911? Because I thought consent could be withdrawn at any time, even with emergencies. But, of course, I could be wrong which is why I am asking.

    :typing

    No, not all rights. But, in the case of something life-threatening, yes.

    Those sats, his history, the act of calling 911. To me spells trouble with a B (as in aBc's).

    EMTs and medics are held to their protocals, standards of care, and the reasonably prudent person standard. What would another person in your situation do. As you can tell by this thread, the majority of pre-hospital people said they'd turn up the o2.


    I can still remember my EMT instructor talking about this in class, which was 12 years ago. Never withhold 02 from a hypoxic pt. We can wean off the vent, but not wean off dead.

    The fact that we all learned that means that it is part of our standard of care. We will NOT be held liable for implementing these standards.
    Implied consent is more than evident here for the reasons previously listed.
  2. by   burn out
    Quote from morte
    as i have said, at least twice, i am not arguing the medical, only the legal.....we are trained that NO IS NO....
    I agree 100% if the patient is competent without suspected hypoxia or hypercapnia.
  3. by   jnette
    Quote from canoehead
    jnette- does your boss have you call the doc before you start CPR, or does she rely on nursing discretion, lol.
    Believe it or not, Canoehead.. I actually asked this very question!

    The answer I was given is that CPR is standard 24/7 regardless. But that 02 is legally still a drug, and for any drug administration we have to have that MD order. She totally understood my thinking, I think she was just concerned about all the "legalities" of it, ie. Medicare audits noting that 02 was administered without an order, etc.

    As for me, I'm more concerned about keeping that patient alive first, worry about the "legalities" later. I seriously doubt the BON would have stripped my license or shut us down because of this... I'd be more concerned about them asking "why DIDN't you give 02" than why DID you. Again, we're between a rock and a hard place. Patient survives, it's "why DID you"... patient crashes and succumbs, you can bet your bottom $ it would be "why DIDN'T you" ?

    I will go with what I feel is right, and I know what I did was correct for this patient. And I would do it again, without question.
  4. by   Medic/Nurse
    well, this is my third post - the topic is still alive and well. we could ask about the patient, but that really has nothing to do with the topic. if all of our practice was judged by the eventual patient outcome...how would any of us really be viewed?

    do not thump me, i do support evidence based practice...but this has turned into something different.

    the question in the op was about justification of the reporting of a paramedic that ignored a home health nurse at the scene. there were collateral issues that deal with the patients right to refuse, the family's motivation and even the pco2 level of the patient.

    we could add the dnr, the patient's recent injury/fracture, the family's bad experiences with the local hospital, the wbc and hgb counts, the cost of the trip from 911 vs. private service fees, the legalities of refusal, nurse vs. nurse debate, nurse vs. medic debate --- and heck, then add good the bad and the ugly for good measure.


    and here we are!


    duthchgirlrn - let me be clear. i am pro nurse. i am pro paramedic. i am absolute in my "pro patient" resolve, too! i am, and will continue to be, always respectful of "other" healthcare providers at scenes. i know this has has been a difficult and emotional issue for you - and i am sorry that you were in this situation.

    please don't construe my "comments" as an attack on hhn's - you have a point, patients do go home sicker and you guys do have to manage those cases. i can only use my experiences to form my reality - in my experience while there are some that may be excellent, but there are many more who cannot manage life threats with the competence that other healthcare providers that specialize in that area do. likewise, i know that i might be able to learn your job, but i know it would not be a good fit for me. so bless you that you do what you do! i will not be doing what you do!

    now, i want to address the "issues" with why this paramedic did not discuss this with you at the scene (and that seems to have gotten a few other posters as well, that the medic did not do the discussion or seemed abrupt). i hope that through this thread the answer to that issue is obvious. but in case it is not - here goes!

    you and the family were emotional, the patient was sick. you were (however nicely) attempting to tell that medic to do something that she knew she could/would not do. (you even went so far as to call the ed doctor to attempt to direct care - so i know you were clearly vested in being right) i think that had she discussed it with you right then, right there, you'd really have had an exchange worth posting. the fact that she listened in a calm manner and then just continued with the vital care of the patient speaks volumes to her restraint. count your lucky stars!



    however, you may feel about it - the medics actions were 100% correct. as to all the collateral issues of refusal - well, i know of no medical board that will give me a "get out of jail free card" or pass - on standards of care and refusal of care - in a hypoxic, febrile, wheezing elderly patient. no where. no how. not now. not ever.

    short of an ems dnr (and the patient presents with agonal respirations/no respirations or pulse - not the case here) or whatever form is recognized by the state you are in - the medic had a duty to provide full (including intubation, electricity, medications - whatever) care to this patient. even a dnr will not allow the medic to do "selective" treatment. the issue of refusal seems to be a big one - i will not bet the farm (or the life of a patient) on a patient (or their family) not finding even a reasonably competent lawyer who could not tear me apart by not treating this patient. this patients right to refusal is in question due to their clinical presentation! no defense for refusal exists here.

    chip193 got the spirit of this 100% correct with the lawyer exchange --- it would be impossible to explain anything other course except treating this patient!

    when given a choice between action or inaction - i will generally choose action everytime. but the bottom line is this:

    i have to make decisions based on what i can explain/defend. i have to keep the best interests of everyone in mind. i have to have reasons and rationales for every action or inaction that i do. i make every effort to make the best decision i can each and every time - none of the why's can save me from a bad decision, but it lessens my chances. action is far easier to explain. but, if i can justify inaction - i'll do just that! but when in doubt i'll choose to err on the side of caution!


    my thanks to the other posters - i have learned a lot. i know that we may have differing views, but thankfully we do!

    please practice safe!

  5. by   Altra
    Thank you for an excellent wrap-up post, NREMT-P/RN.
  6. by   morte
    so you can justify assault and battery, because you are going to do what ever you see fit?
  7. by   cardiacRN2006
    Quote from morte
    so you can justify assault and battery, because you are going to do what ever you see fit?

    Assault and battery (alive pt) vs. failure to intervene (possible dead pt).......hmmmm.......
  8. by   Medic/Nurse
    Hey there morte -

    Yep, give me a good old ASSAULT and BATTERY charge over a lawsuit where I was REALLY NEGLIGENT any day!

    CRIMINAL cases have to be proven beyond a reasonable doubt - read 100% WRONG!

    CIVIL cases just need 51% to find in favor of a plaintiff.

    NOT EVEN A DIFFICULT DECISION HERE!

    No assault or battery existed. The patient was IN EXTREMIS in this case. I would have had to act on an applied consent. Nothing said in "the heat of the moment" would have allowed me to leave this patient. NOTHING that was said could stop what was started with the 911 entry. Unfortunate, but true.

    So, when faced with 2 bad decisions, I'll pick the lesser.

    I will chose what I can defend. ACTION vs. INACTION. NO CONTEST!

    Thanks, nice point!

    Practice SAFE!
  9. by   Medic/Nurse
    Thanks, MLOS!

    I doubt that my humble post will be the wrap up though.

  10. by   Sheri257
    Quote from NREMT-P/RN
    CRIMINAL cases have to be proven beyond a reasonable doubt - read 100% WRONG!

    CIVIL cases just need 51% to find in favor of a plaintiff.
    Good point.

    :typing
  11. by   morte
    Quote from NREMT-P/RN
    Hey there morte -

    Yep, give me a good old ASSAULT and BATTERY charge over a lawsuit where I was REALLY NEGLIGENT any day!

    CRIMINAL cases have to be proven beyond a reasonable doubt - read 100% WRONG!

    CIVIL cases just need 51% to find in favor of a plaintiff.

    NOT EVEN A DIFFICULT DECISION HERE!

    No assault or battery existed. The patient was IN EXTREMIS in this case. I would have had to act on an applied consent. Nothing said in "the heat of the moment" would have allowed me to leave this patient. NOTHING that was said could stop what was started with the 911 entry. Unfortunate, but true.

    So, when faced with 2 bad decisions, I'll pick the lesser.

    I will chose what I can defend. ACTION vs. INACTION. NO CONTEST!

    Thanks, nice point!

    Practice SAFE!
    so you BLATANTLY ADMIT that you would commit A+B for your own purpose, ie it would be easier to defend....remember this patient wasnt refusing care....clearly and apparently cogently stated NO only to the increase in oxygen....
    and could you explain what "applied" consent is please?
    Last edit by morte on Feb 1, '07 : Reason: adding
  12. by   canoehead
    morte- I admit I would.

    I haven't based my care decisions on lawsuit vrs no lawsuit because I just wasn't wired that way. Luckily in our nursing school program they approached it with a "what would you say to the family" if your actions caused harm. I explained in a previous post how the bizarre presentation of the patient and family would affect my decisions if I was an EMT. With a patient so sick I wouldn't want to hang around for a debate, the patient could die before we reached a full understanding. The term I think the previous poster meant was "implied" consent, meaning that if you call for the services of an ambulance it implies that you want those services, and treatment with O2 is part of the deal. If all you want is a driver and a more comfortable ride you call a cab, or a limo, or whatever.

    At any point the family or patient can change their minds and say they refuse care, sign the paper and send the ambulance on their way. But if they get in the rig they have agreed to do it safely as defined by the ambulance company, it's medical supervisors, and by extension, the EMT. So they agree for example, to wear seatbelts in the seat assigned to them, not smoke cigarettes inside the rig, and cooperate with treatment deemed necessary. No picking and choosing, unless it's been discussed in the protocols ahead of time.

    The OP and the family could contact the ambulance company now and say they want to put a partial DNR on file (I don't know what the paper would actually be called), and they could discuss it rationally. An emergent emotion filled moment is a bad time to figure out deviations from standard care, that's why EMT's have protocols. It's a real patient safety issue, and TPTB have acknowledged that in some cases extra O2 makes things worse, but they can fix it in the ER, but withholding O2 can cause problems that aren't fixable, so give the O2 in ALL situations.

    The other option could be calling medical control for an order to deviate from protocol. With the clinical presentation I doubt such an order would be given. But if it crossed the EMT's mind to call he/she might have reasonably assumed there was no time to call. With sats in the 70's that's what I would have thought- "let's get this guy in the rig and haul ass." The EMT undoubtedly thought the whole situation was nuts, the patient was crashing, and the wisest move would be to get the patient to the ER alive and let them figure out the legalities.

    And that's what happened. The patient made it alive, and here we sit over several days still not able to agree on what he/she should have done, or whose rights were violated. If we can't come to a clear conclusion with days to figure it out how can we expect the EMT to do so under pressure and in a few seconds.
  13. by   Medic/Nurse
    Nah, not my "own" purpose...but patient centered care!

    Lets see..the solution would let her just keep getting hypoxic --- then she passes out and NOW...TA DA - NO NEED FOR REFUSAL ... I just messed up. TRUE ACLS and Emergency Care is CODE PREVENTION...NOT just CODE PERFORMANCE.

    What part of IN EXTEREMIS do you not understand?
    What part of an "excited utterance" is difficult to understand?

    That is the rub with critical states...patients nearing the "end game" are not capable for the authority as to specific procedures. "No no oxygen", "no don't touch my leg" (from the multi-trauma hypovolemic patient as I'm getting ready to reduce that open femur fx). Sure NO may mean NO, but when altered patient states/failure to treat are involved ... the only NO that matters is what I KNOW.

    When you call, you by proxy allow EMERGENCY TREATMENT by 911 providers. Implied consent definition (for the record) - a manifestation of consent/acceptance of something through conduct or action, including silence.

    But, before we go down the "slippery slope" lets see how competence is decided as to ability to direct one's care. I'll bet there is not a LEGAL AUTHORITY in this country --- State, Federal District, Federal Circuit, US Supreme Court that will hold that a patient in the throws of an emergent illness with marked hypoxemia will be able to make an INFORMED DECISION!

    Practice SAFE!

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