1. CBT-931-EMT12 Death and Dying

2. Introduction
This presentation discusses the withholding of resuscitation efforts from patients with terminal conditions who do not have written DNR orders.
These guidelines have been implemented by King County, Washington and are not necessarily practiced elsewhere.
If you are an EMT outside King County, please consult with your agency's medical director regarding withholding resuscitation.

3. Introduction
Changes in society require an expanded knowledge of death and dying
Aging population
More terminal illnesses & chronic health problems
Shorter hospital stays
Improved technology allowing chronically ill to return home

4. Outcomes Practical Skills Learning Outcomes
Demonstrate patient assessment in simulated death & dying scenarios
Show appropriate treatment protocols in simulated death and dying scenarios
Demonstrate appropriate communication skills when interacting with patient and family in simulated death & dying scenarios
Learning Outcomes
Identify the stages in the physiology of death
Determine evidence of dependent lividity and rigor mortis
Ascertain compelling reasons not to resuscitate a patient
State the differences between a DNR order, POLST, and a Living Will
Deal with family members who disagree about resuscitation the dying patient
Identify reasons why a family would call 911 when a death is expected

5. Terms
advance directive — Instructions, usually in writing, that address an individual’s medical treatment preferences.
biological death — Point at which brain cells start to die generally after 4 to 6 minutes without oxygen.
clinical death — Moment at which heartbeat and breathing stop.
DNR order — A do-not-resuscitate (DNR) order is a document that informs medical personnel not to attempt a resuscitation.

6. Terms
dependent lividity — A reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the blood vessels evident in the lower lying parts of the body in the position of death.
palliative care — Providing measures that relieve or soothe the symptoms of a disease or disorder without effecting a cure, for example, providing oxygen therapy.
Physician’s Orders for Life Sustaining Treatment (POLST) — A specific type of advance directive that communicates the treatment and resuscitation wishes of seriously ill patients.
rigor mortis — A stiffening, usually occurring several hours after death.

7. Cessation of Heartbeat
In general, three stages occur in the dying process:
If cardiac arrest occurs first process of dying is rapid
With other causes:
May occur over hours, days
May become dehydrated
May have irregular, agonal or noisy respirations
May have seizure activity
May lose control of bowel, bladder 1
Cessation of heartbeat and breathing

8. Cessation of heartbeat and breathing
Dependent Lividity 1
A few minutes after circulation stops:
Blood begins to pool and settle
Appears as blotchy black-and-blue or reddish marks
Cessation of heartbeat and breathing 2
Dependent lividity

9. Cessation of heartbeat and breathing
Rigor Mortis
A few hours after death:
Muscle cells contract and stay contracted
Stiffening begins with small muscles (fingers, neck and jaw), progresses to the extremities and pelvis
After 12 hours:
Degradation of protein in muscles
Body becomes limp 1
Cessation of heartbeat and breathing 2
Dependent lividity 3
Rigor mortis

10. Assess the Scene
In some cases the decision whether or not to start resuscitation is easy
Example  witnessed cardiac arrest

11. Begin resuscitation if you aren’t sure whether or not to proceed.
Assess the Scene
Situation less clear, first arriving unit should take following actions:
Survey scene for possible hazard or crime
Check for ABCs, injuries incompatible with life
Check for dependent lividity & rigor mortis if unwitnessed arrest or unknown down time
Begin resuscitation if you aren’t sure
whether or not to proceed.

12. Assess the Scene A thorough scene survey includes: Ambient temperature
Location where patient was found
Position/anything unusual noted
Potential insulators that complicate the determination of "down time"
Presence of hospital equipment

13. History and Physical Exam
Gather information from witnesses or family members:
Witnessed or unwitnessed arrest
Time last seen
CPR attempts by witnesses and quality of CPR
Preceding events (complaints, s/s, activity)
Medical history
Baseline level of functioning
Physician & hospital affiliation
DNR orders, POLST or patient/family wishes

14. History and Physical Exam
When conducting physical exam, note:
General condition of body (emaciated, well-nourished, jaundiced, etc.)
Body temperature
Signs of trauma
Signs of death (dependent lividity, rigor mortis)

15. Withholding Resuscitation
You may withhold or stop resuscitation if any of the following are present:
Injuries incompatible with life
Dependent lividity, rigor mortis
Advance directive stating resuscitation be withheld
Compelling reasons to withhold resuscitation

16. Withholding Resuscitation
If a resuscitation effort has been initiated & you are provided an advance directive or compelling reasons the effort should be withheld, STOP.

17. Withholding Resuscitation
You should not start CPR when:
Patient’s injuries incompatible with life such as decapitation
Patient or family member presents an advance directive
Obvious signs of lividity
Compelling reasons

18. Compelling Reasons
Patients who are mentally competent have the right to refuse medical care, including resuscitation.
Patients who are dying have the same rights.

19. Compelling Reasons
Permit EMS personnel to withhold resuscitation in cardiac arrest when two criteria are BOTH present:
End stage of terminal condition
Written or verbal information from family, caregivers, or patient stating patient did not want resuscitation

20. Examples BOTH criteria met Criterion 1: met -- end-stage cancer
65-year-old man with end stage liver cancer died at home. His wife meets you at the door saying she called 911 because she wasn't sure if he was actually dead. She states his condition was terminal and he didn't want any kind of resuscitation effort.
Criterion 1: met -- end-stage cancer
Criterion 2: met -- verbal request stating that the patient did not want a resuscitation effort
ACTION: withhold resuscitation

21. Examples Situation where one criterion met but not the other
50-year-old man collapsed in cardiac arrest while arguing with his estranged wife. She tells you not to attempt resuscitation in spite of his apparent good health.
Criterion 1: not met – no evidence of a terminal condition
Criterion 2: met - verbal request from family that resuscitation be withheld
ACTION: begin resuscitation attempt

22. Palliative Care You can make a dying patient more comfortable with:
Appropriate positioning
Suctioning or controlling bleeding
Contacting the patient’s private physician or hospice
Requesting a medic unit if you feel pain management is needed
Family may benefit from your support and assistance

23. Why Families Call 911
Reasons why people call 911 for an expected death:
Confusion
Uncertainty
Guilt
Inappropriate information from other agencies
Need for confirmation of death

24. Legal and Ethical Concerns
Washington State
By following guidelines in this presentation, you are protected from legal liability by RCW when you act in good faith and in accordance with your training.

25. Legal and Ethical Concerns
What if family members disagree?
Signed DNR order reflecting patient’s wishes, supported by family member who has power of attorney
Strong support for withholding resuscitation, even if other family members disagree
Verbal statement from family member who has power of attorney or close relative should be given priority over someone not as close

26. Advance Directives Three types of advance directives: DNR Order POLST
Living Will

27. DNR Order
Originates and is signed by physician AND patient or surrogate
Generally for people near the end of their natural lives
Deals primarily with CPR/resuscitation
EMS personnel may honor DNR orders

28. POLST Physician’s Orders for Life-Sustaining Treatment
Originates and is signed by physician AND patient or surrogate
Generally for people near the end of their natural lives
Deals with both CPR/resuscitation and other types of treatments such as antibiotics, nutrition and hydration
EMS personnel may honor POLST directives
Instructors: there is a better image of the actual document here:

29. Living Will Easily obtained by anyone; no physician signature required
Generally for adults at any point in their lives
Does not deal with emergent treatment such as resuscitation, but rather, treatment of a future condition
EMS personnel may take a living will into account as an expression of a patient’s wishes to invoke compelling reasons

30. Summary
You can determine whether or not to begin resuscitation by assessing pulse & breathing, checking for lividity & rigor mortis
Do not initiate resuscitation if:
Injuries are incompatible with life
A valid advance directive is present
Lividity/rigor mortis are present
Compelling reasons to withhold resuscitation

31. Summary
You may withhold resuscitation if there are compelling reasons; two criterion must be met:
End stage of terminal condition
Written or verbal information from family, patient, or caregivers stating patient did not want resuscitation
Document compelling reasons when used as basis for withholding resuscitation

32. Summary When there is doubt—initiate resuscitation.
Don't make assumptions about the family's desire for resuscitative efforts without asking.