:O) End of Life Care and Death Notification

End of Life Care / Death Notification

Objectives Legal aspects of end of life care Palliative care Death notification Discussion

DNR Made by a doctor, for a facility Expires when the patient leaves the facility Doctor will likely consult with the patient but is not required Effective for cardio or pulmonary resuscitation

CPR Directive Issued by the patient or a proxy Effective for cardio or pulmonary resuscitation There is not a specific form Does not have to be an original

Living Will Details life sustaining treatment if you have a terminal condition Only goes into effect 48 hours after 2 doctors determine you have a terminal condition

MOST

Legal Terms Medical Durable Power of Attorney Someone to legally make medical decisions when the patient can not Proxy A person that is chosen to make medical decisions for the patient

Legal Issues Must follow orders MDPOA’s and Proxy’s are required to follow orders What do we do when there are no orders?

Termination Discussion When do you have this discussion with your patient? Would you be surprised if this patient died? Establish rapport Give advice Don’t get into a power struggle

Palliative Care 70% of patients prefer comfort measures but 2/3 of these patients end up in the ICU Consult with hospice for orders Comfort care does not rule out going to the hospital

Palliative Treatment Pain / Respiratory Distress Opiods Nausea / Vomiting Zofran Anxiety / Delirium Benzo and/or Haldol Narcotic Converting Calculator

Death Notification

GRIEV_ING GGather; gather the family; ensure that all members are present. RResources; call for support resources available to assist the family with their grief, i.e., chaplain services, ministers, family and friends. IIdentify; identify yourself, identify the deceased or injured patient by name, and identify the state of knowledge of the family relative to the events of the day. EEducate; briefly educate the family as to the events that have occurred in the emergency department, educate them about the current state of their loved one VVerify; verify that their family member has died. Be clear! Use the words “dead” or “died.” _Space; give the family personal space and time for an emotional moment; allow the family time to absorb the information. IInquire; ask if there are any questions, and answer them all. NNuts and bolts; inquire about organ donation, funeral services, and personal belongings. Offer the family opportunity to view the body. GGive; give them your card and access information. Offer to answer any questions that may arise later. Always return their call.

Foundations for Interaction Incorporate and gather all family members present Identify and introduce yourself Know who you are speaking with Do the notification with someone else Be in a private place, with family sitting down When possible, get at or below their eye level

Making the Notification Be direct and explain the “___” has died in spite of your best efforts Use the word “died” or “dead” Tell the family what you know about the patient’s condition and what actions were taken during the resuscitation Listen carefully and answer questions from the family Give the family space and time to have an emotional moment Discuss what will happen next Offer to assist in contacting appropriate resources such as other family members and clergy

Typical Family Reactions Crying, anger, hostility, sobbing, blaming Nothing, blank stare, numbness or collapsing Disbelief or denial Guilt Praying Hysteria Fear

Helpful Phrases “I am sorry for your loss” “How can I help?” “It is normal for you to react this way” “It is harder than most people think” “I know this is painful/hard to accept”

Unhelpful Phrases “You shouldn’t feel that way” “At least …” or “You’re lucky that …” “I know how you feel, my ___ died recently” “You have to focus on the good memories” “At least he/she died in his/her sleep” “He/she is in a better place now”

EMS is really good at this Studies show that almost 100% of people are satisfied with the medical care and emotional support provided by EMS after field termination. Edwardsen EA, Chiumento S, Davis E. Family perspective of medical care and grief support after field termination by emergency medical services personnel: a preliminary report. Prehospital Emergency Care Oct-Dec;6(4):440-4

Resources End of Life Care Information for EMS Providers About CPR Directives MOST form Code of Colorado Regulations 6 CCR How Doctors Die; It’s Not Like the Rest of Us, But It Should Be Death Notification - GRIEV_ING CPR Directive This presentation jon mueller