Prehospital Providers' Perspectives about Online Medical Direction in Emergency End-of-Life Decision-Making.

Background: End-of-life treatment decisions present special challenges for prehospital emergency providers. Paramedics regularly make value-laden choices that transcend technical judgment and professional skill, affecting the type of care, how and to whom it is provided. Changes in prehospital emergency care over the last decade have created new moral challenges for prehospital emergency providers; these changes have also accentuated the need for paramedics to make rapid and reasoned ethical judgments. Objective: The purpose of the study was to explore the decision-making process that occurs when prehospital emergency teams respond to an end-of-life call with a focus on how state authorized documents such as a Non-Hospital Do Not Resuscitate (NHDNR) or Medical/Physician's Orders for Life-Sustaining Treatment (MOLST/POLST) or lack thereof inform decision-making. This paper presents the specific circumstances that informed the need for intervention from Online Medical Direction (OLMD) framed in the perspectives and words of the prehospital providers seeking that assistance. Methods: This study involved in-depth in-person interviews with 50 providers to elicit participants' experiences in their own words using a semi-structured interview instrument. Interviews were audio recorded and transcribed with permission. Results: Five themes emerged that illuminated how and when OLMD was involved in emergency end-of-life decisions: Termination of Resuscitation (TOR); Family Revoked DNR; Missing Documents; No Documents and No CPR; and Unusual Situations. Participants illustrated how the decision to terminate efforts was best-supported when it was made by collaboration between the on-scene provider and OLMD. Participants described ethical dilemmas when families asked them to initiate CPR in the presence of DNR orders and cognitive dissonance when CPR has been initiated but a valid DNR/MOLST is subsequently located. Conclusions: The study findings demonstrate the invaluable contribution of OLMD for complex end-of-life care decisions by prehospital providers, especially when there are difficult legal, ethical, and logistical questions. OLMD provides far more than technical support.

Managing Death in the Field: Prehospital End-of-Life Care.

CONTEXT: Historically, the focus of prehospital care has been life-saving treatment. In the absence of a nonhospital do-not-resuscitate (DNR) order, prehospital providers have been compelled to begin and continue resuscitation unless or until it was certain that the situation was futile; they have faced conflict when caregivers objected. OBJECTIVES: The purpose of the study was to explore prehospital providers' perspectives on how legally binding documents (nonhospital DNR order/medical orders for life-sustaining treatment) informed end-of-life decision making and care. METHODS: This exploratory study used mixed methods in a sequential nondominant two-stage convergent quantitative and qualitative design. Phase I involved the collection of survey data. Phase II involved in-person semistructured interviews. RESULTS: Surveys were completed by 239 participants, and 50 follow-up interviews were conducted. Survey data suggested that 73.7% felt confident when there was a DNR order and they did not initiate resuscitation, and 58.2% felt confident working through family disagreement when cardiopulmonary resuscitation was requested but there was a DNR; 66.1% felt confident explaining the dying process when death was imminent, and 55.7% felt comfortable telling a family that a patient was dying. Four themes emerged: changing standards of care; eliminating false hope; transitioning care from patient to family; and transferring care after death. CONCLUSION: Prehospital providers provide support and care when they tell families that someone has died. Being able to comfort and be present with acute grief on scene is an important and evolving role for prehospital providers who manage death in the field.