Case summary:

An ALS crew responded to a 90s woman who was reportedly altered.  When the crew arrived at the assisted living facility, the staff reported she was confused but also reported they did not know the patient at all or her baseline mental status.  When the patient was asked what was going on or if she would go to the hospital for assessment, she refused transport and became angry and frustrated by any attempt to move her towards the stretcher or the ambulance.  The crew called the patients son who was the patient’s healthcare power of attorney (POA).  He informed the crew that the patient was acting her normal self as well as that the patient’s code status was Do Not Resuscitate (DNR) comfort care meaning that he wanted to focus all on going care on making her as comfortable as possible.  He also reported she had recently complained of arm pain.  She had this pain evaluated a few days ago but was still reporting this pain so the son requested the patient be transported to have the pain evaluated further.  Despite the request of the son, the patient continued to refuse transport as well as any assessment by the crew on scene.  The son reports that he would not want to force her to go against her will.  The crew did not feel that the patient had capacity so they followed the son’s request to not transport against her will or assess further (including obtaining vitals).   The son planned to stay with the patient for a few hours and watch her as well as planned to call EMS if something changed and he felt she needed transport at that time.  The crew cleared the scene and returned to base.

Highlights of the case:

Assessing decision making capacity

Decision making capacity is what allows patients to make their own medical decisions.  To have capacity, a patient needs to demonstrate that they understand what is going on, can appreciate the risks of all the choices they have, can reason through the choices logically, and can express the choice they want.  If a patient is making a care decision that we do not think is best, this should trigger us to assess capacity.  If we think they have capacity, we are legally not allowed to do anything against their wishes even if we think it is risky.  If a patient does NOT have capacity, then we need to relay on the healthcare power of attorney to make the decision for the patient.  If no healthcare power of attorney is available, then we are to do what we believe is best for the patient.  In this case, the patient could not demonstrate capacity, and the crew therefore needed to rely on the patient’s son to make decisions for her.

Ensuring that patients with capacity are making the decision

Often a patient’s official healthcare power of attorney (POA) will attempt to make decisions for a patient.  The key thing to remember is that if a patient has capacity, it is the patient, not the POA, who makes the decisions.  The only time that the POA gets to make the decision is if the patient loses capacity.  Many POAs do not understand this so it is important to remind them of this key component.  This was not one of those cases since the patient lacked capacity.  The patient’s son was clearly thinking about his mother’s best interest and was being a great patient advocate.

Get collateral information whenever possible

We are frequently called to care facilities to assess and transport patients who are reportedly confused in some way.  Acute confusion is a medical emergency since many of the causes can be life threatening.  However, it is not ideal when staff at these facilities report they feel that the patient is confused but also do not know the patient at all or their baseline.  This is because chronic confusion from something like dementia is not an emergency and is very likely the reason the patient is in the care facility to begin with.  While these care facilities should he knowledge about each of the people they care for, this is unfortunately not often the case.  We want to try and get collateral from someone who knows the patient (such as family or the prespecified healthcare POA).  Care facilities should have this contact info available, and it is worthwhile to call prior to transport to make sure the story reported to you by staff is accurate.  In this case, the patient was confused and lacked capacity to make her own decisions; however, this was her baseline.  In the absence of getting collateral from the son, we would be required to transport this patient against her will since she lacked the capacity to refuse.  This would have not been in her best interest and transport to the hospital is not without risk to the patient our us as responders.  By calling the son and getting accurate information from him, the crew was able to confirm that there was no acute confusion and care for this patient in a way that lined with her goals of care.

Do Not Resuscitate Comfort Care (DNR-CC) Status

When we care for patients, our goal is to provide the best possible care that is in line with the patient’s goals of care.  In the state of Ohio, DNR-CC means that the patient wants to focus their care on being as comfortable as possible instead of on life preservation.  Some of these patients might be in hospice, but this is not always the case since hospice status requires that a physician believe that the patient is likely to die within six months.  Some patients who are expected to live longer than six months still want to focus their care on managing symptoms leading to them becoming DNR-CC.  Other states have similar designations, so it is important to know the exact meaning of each code status as it applies to the state where you work.  Whenever we are caring for patients with this kind of code status, we should confirm that this is truly what they want and then ensure that the care we provide corresponds with the patient’s goals.  In the case of this patient, the crews’ assessment and attempts to transport was causing the patient a great deal of distress and likely was causing more harm to her then the arm pain she might have been having.  The decision made by the son and the crew to not force the assessment or transport was the best option for this patient and her treatment goals.