End of Life Care Pamela Murphy, MD, FACEP HVREMAC Chair Physician Advisor, ORMC Adjunct Professor, Touro Medical College

Determination of obvious death Overview Advance directives Provide means for communication of patients’ wishes at their ends of life Determination of obvious death When resuscitation is not likely to result in meaningful benefit to the patient Termination of resuscitation When further resuscitation is not likely to result in meaningful benefit to the patient This presentation discusses the 2016 NYS Collaborative Protocols sections concerning EMS involvement in end of life issues. The accompanying protocols include: (1-5) Cardiac Arrest: Determination of Obvious Death (1-6) Cardiac Arrest: Termination of Resuscitation (2-3) Advance Directives It is important that EMS respects the wishes of patients at the end of their life to the extent that the law allows and requires. It may be necessary to consult medical control to determine the most appropriate course of action in some cases. End of life issues are complex. This presentation provides some insight into what the provider may/must honor on his or her own and what requires medical control consultation. Note: There is additional information contained throughout the presentation in the notes section of the PowerPoint

Laws are in place to facilitate EMS compliance with these wishes End of Life Care Patients have the right to end of life care consistent with their wishes Laws are in place to facilitate EMS compliance with these wishes Advance directives provide means for communication of these wishes Some advance directives may be honored directly by EMS and others may require medical control consultation “Comfort care” does not mean no care; it means that the focus of care has changed from that of a diagnostic or curative end to that of maximizing comfort and minimizing suffering, according to a patient’s wishes at the end of his or her life.

Types of Advance Directives EMS may honor: MOLST or eMOLST NYS form DOH-5003 Sections on resuscitation and intubation Section on IV therapy and transportation to the hospital Non-hospital DNR NYS form DOH-3474 Bracelet EMS requires medical control to honor: Living will Health care proxy For patients who are awake and have the capacity to make decisions, their wishes must be followed in accordance with standard consent procedures. These patients have the right to supersede or revoke advance directives. For patients who are unable to make decision, including those who are unconscious, advance directives help to convey their wishes.

Medical Orders for Life Sustaining Treatment MOLST or eMOLST Medical Orders for Life Sustaining Treatment Valid for all of NYS Replacing non-hospital DNR MOLST (DOH-5003) is a bright pink form Must be signed by a physician to be valid Photocopies are acceptable eMOLST is an electronic version of the form that may be printed Electronic signatures on the printed eMOLST form are considered valid

MOLST/eMOLST Now Statewide Originally, these were only used in Monroe and Onondaga counties as part of a pilot program Some old forms may still include language to restrict use to these two counties Ignore this restriction if it is printed on the form* MOLST forms are valid statewide Most of the MOLST forms have been updated and do not have the language that restricts use to Monroe and Onondaga counties. It is possible, however, that old forms may still be in use. Even if the MOLST is completed on the old form (with the restriction to these two counties) the form is still considered valid throughout NYS and the restriction should be ignored. *Chapter 197 of the Laws of 2008 signed by Gov. David Paterson make MOLST forms valid statewide and render the restriction to Monroe and Onondaga Counties obsolete. This is reflected in NYS DOH Policy 08-07.

MOLST/eMOLST Section A - DNR This section ONLY applies to those in cardiac arrest (not breathing and no pulse) One box indicates that the patient wishes to be DNR (AND – Allow Natural Death is also listed as a term) One box indicates that full resuscitation should be initiated YOU MUST read the form to assure you follow the patient’s wishes and the doctor’s order (DNR=Do Not Resuscitate AND = Allow Natural Death DNI=Do Not Intubate) AND is a newer term that is sometimes easier for patients and families to understand If the DNR box is checked, no BLS or ALS care is to be provided if the patient is in full cardiopulmonary arrest (no breathing, no pulse) even if resuscitation was previously started. If the full resuscitation box is checked, then the provider should implement all indicated resuscitation interventions to his or her level of care Section E contains instructions for patients in progressive or impending pulmonary failure, even if they are still breathing and still have a pulse. Section E may allow for non-invasive positive pressure ventilation such as BVM, CPAP, or Bi-PAP.

MOLST/eMOLST Section E - DNI This section applies to patients, even if they are not in cardiopulmonary arrest Instructions may extend beyond simply intubation The “Instructions for Intubation and Mechanical Ventilation” are to be honored by EMS It can be difficult to watch a patient in respiratory distress who has a MOLST that indicates DNI – if you have any questions, please call medical control (DNR=Do Not Resuscitate DNI=Do Not Intubate) If the DNR box is checked, no BLS or ALS care is to be provided if the patient is in full cardiopulmonary arrest (no breathing, no pulse) even if resuscitation was previously started. If the full resuscitation box is checked, then the provider should implement all indicated resuscitation interventions to his or her level of care Section E contains instructions for patients in progressive or impending pulmonary failure, even if they are still breathing and still have a pulse. Section E may allow for non-invasive positive pressure ventilation such as BVM, CPAP, or Bi-PAP.

MOLST/eMOLST Other General: Advance Directives (2-3) protocol indicates that the provider should honor any valid directive on the signed document, copy, or printed MOLST/eMOLST IV fluids may be indicated or withheld Transport to the hospital may be withheld If there is a question regarding the most appropriate action to take, based on instructions on the MOLST/eMOLST, consult medical control The other sections of the MOLST/eMOLST include instructions regarding IV fluid and potential limitations on transportation to the hospital. Note that transportation to the hospital may be indicated, if pain or severe symptoms are not able to be adequately controlled where the patient is located. Consult medical control if there are questions. Use good faith judgement Health Care Proxy and Living Will are separate from MOLST/eMOLST although the MOLST/eMOLST may indicate that these documents exist separately, if the appropriate box is checked. Health Care Proxies and Living Wills are addressed separately in this presentation

Non-Hospital DNR Non-Hospital Order Not to Rescusitate (DOH-3474) is being replaced by MOLST/eMOLST This form, or the accompanying NYS approved bracelet or necklace, may still be in use and is still considered valid This document only applies to patients who are in cardiac arrest (no breathing and no pulse) A valid, signed form must be honored unless it is known that it has been revoked Use good faith judgment to determine if the document has been revoked.

Multiple Documents If there are multiple non-hospital DNR and/or MOLST/eMOLST forms present, the valid document with the most recent date implementation/review should be honored Only the MOLST/eMOLST has direction regarding intubation so that form should be honored regarding DNI/ventilation Check section F of the MOLST/eMOLST to determine when the document was last reviewed Section F of the MOLST/eMOLST may contain information regarding revocation or replacement of the document. This section may also indicate that the document was reviewed and renewed on a particular date; this date should be considered when determining which document is most current. Use good faith judgment to determine if the document has been revoked. Consult medical control, if there are questions.

DNR orders only apply if the patient is in cardiac arrest Indicated Care DNR orders only apply if the patient is in cardiac arrest MOLST/eMOLST may indicate additional treatment restrictions No other limitations of care should be assumed Full, routine care should be given unless there are explicit instructions to withhold certain treatments on these documents. In other cases, medical control must be consulted if additional limitations should be implemented. In some cases, palliative care may be indicated. Palliative care (with medical control order, as required) may include any or all of the following, within the provider’s scope of practice, unless otherwise prohibited by advance directive: Airway suction Pain management Anxiolysis Sedation Fracture splinting Positioning for comfort / ease of breathing Oxygen administration

Directives from a health care proxy cannot be honored by EMS Legal document designating an individual to make health care decisions for a patient when he or she cannot Directives from a health care proxy cannot be honored by EMS Contact medical control for direction regarding treatment wishes conveyed by a health care proxy The health care proxy is only authorized to make decisions for the patient if the patient does not have the capacity to make those decisions for himself or herself. While the law does not grant EMS providers the ability to honor a health care proxy on their own, the most appropriate care in accordance with the patient’s wishes should be given. Medical control exists to provide direction to providers in cases that are not covered by standing order and when discretion is required. The medical control physician can exercise judgment to help facilitate the provision of the most appropriate care for the patient.

This is not a physician order Living Will Legal document indicating a patient’s wishes regarding medical care in circumstances when they cannot express informed consent This is not a physician order Directives indicated on a living will cannot be honored by EMS Contact medical control for direction regarding treatment wishes conveyed by a living will The living will only takes effect if the patient does not have the capacity to make treatment decisions for himself or herself. While the law does not grant EMS providers the ability to honor a living will on their own, the most appropriate care in accordance with the patient’s wishes should be given. Medical control exists to provide direction to providers in cases that are not covered by standing order and when discretion is required. The medical control physician can exercise judgment to help facilitate the provision of the most appropriate care for the patient.

Durable Power of Attorney Not specific to healthcare Can grant broad power for an individual to make decisions one’s behalf or be limited to decisions regarding certain legal or financial matters In NYS, there must be a separate Health Care Proxy form completed in order to designate a surrogate decision maker for healthcare-related issues The Power of Attorney in NYS cannot make healthcare decisions for a patient who lacks the capacity to do so without having a separate Health Care Proxy form; see Health Care Proxy.

Determination of Obvious Death Outlines criteria for withholding or stopping resuscitation efforts for cases in which resuscitation is not likely to result in meaningful benefit to the patient Any single criterion is sufficient to determine obvious death in the apneic and pulseless patient: Valid DNR, MOLST, or eMOLST indicating no resuscitation Signs, such as decomposition, rigor mortis, dependent lividity (livor mortis), or injury incompatible with life Traumatic arrest without organized ECG activity (see notes) Patient submerged for greater than one hour in any water temperature There is risk to providers, the public, and other patients associated with patient resuscitation. Providers are subject to injury and blood borne pathogens. Providers and the public are subject to motor vehicle collisions. Other patients are subject to the risk of finite resources being diverted to the patient being resuscitated. While out of hospital resuscitation is effective in certain instances and should be implemented to the fullest extent, when appropriate, there are some instances in which resuscitation is unlikely to provide any meaningful benefit to the patient. In these cases the very real risks associated with resuscitation do not outweigh the negligible benefit in these very specific instances. Examples of injuries incompatible with life include decapitation, burned beyond recognition, and massive open or penetrating trauma to the head or chest with obvious organ destruction. A patient in traumatic cardiopulmonary arrest without organized cardiac activity on the ECG should not be resuscitated, provided there is significant blunt or penetrating trauma. This means that the trauma should be included in steps one, two, or three of the criteria set forth in the CDC Trauma Triage resource included in the protocol document. If the patient does not meet this definition of significant trauma, then this suggests that the cardiac arrest is not secondary to the trauma and the patient is excluded from this criterion. If there is organized cardiac activity on ECG, then resuscitation should be initiated, as indicated in the appropriate cardiac arrest protocol (including bilateral chest decompression, if indicated and within the provider’s scope of practice). The literature regarding cardiac arrest secondary to submersion in water was reviewed and the risks and benefits of resuscitation were considered. Submersion of a patient under water for greater than one hour constitutes obvious death, regardless of the water temperature, provided there is a reliable time of submersion. If uncertainty exists as to the time of actual submersion, resuscitation may be indicated.

Termination of Resuscitation Outlines standing order criteria for stopping resuscitation efforts for cases in which further resuscitation is not likely to result in meaningful benefit to the patient For this protocol, all of the following criteria must be met: Age 18 or older Arrest not witnessed by a bystander or by EMS No bystander administered CPR No AED or manual shock delivered No return of spontaneous circulation at any time At least 20 minutes of resuscitation has been provided Again, there is risk associated with resuscitation. These standing order criteria are stringent and all must be satisfied for standing order to be authorized. There may be situations that are not amenable to termination in the field for various reasons. This protocol does not necessitate the termination of resuscitation in those circumstances. The protocol does, however, identify patients for whom medical benefit is negligible and allows the provider to stop resuscitation without consulting medical control. There may also be cases that do not meet the standing order criteria for termination of resuscitation in which medical control may authorize termination of efforts.

Communication of Death Is difficult… be honest and empathic Notifying the family of the death of a loved one is a difficult, yet acquired skill Providers should be familiar with the appropriate communication skills required and have practice with the delivery of bad news Suggested: Iserson, KV. Grave Words (text, pocket protocols, and other resources) Published by Galen Press http://www.galenpress.com/018.html ISBN: 1-883620-02-3 Catalog # 018 $38.95 Paper 343 pages, Bibliography, index 1999 (Implies no endorsement. No relevant financial or non-financial relationship.)