A host of factors — public perception the most powerful among them — often force emergency medical services to transport deceased patients to the ED after prehospital resuscitation fails, even though national guidelines support abandoning futile efforts.
But these barriers are usually beyond paramedics' control, whether they are state laws mandating transport, payers who won't reimburse without it, or family members who insist on hospital care.
“Consider the case of the 92-year-old grandmother,” said Comilla Sasson, MD, a lecturer in emergency medicine at the University of Michigan Medical School and the Robert Wood Johnson fellow who was lead author of a report on the issue. (Circ Cardiovasc Qual Outcomes. (2009;2:399.) Paramedics arrived to attempt resuscitation on the elderly woman, and when she did not respond, they put her in the back of the vehicle and sped off to the hospital, siren keening and lights flashing.
“As a medical community, we are sending a message that grandma is going to be fine. In truth, after 20 minutes, there is nothing more to be done in the emergency department than we could do in the prehospital setting. Overall, survival to hospital discharge after an out-of-hospital cardiac arrest has stayed the same for 30 years. You give a false sense of hope when you transport that patient to hospital,” Dr. Sasson said.
Dr. Sasson and her colleagues held three focus groups at the 2008 meeting of the National Association of Emergency Medical Services Physicians to identify which policies or perceptions might affect the ability of paramedics to follow national guidelines for terminating resuscitation outside the hospital. They found three:
- ▪ Payers often will not reimburse for out-of-hospital care unless the patient is transported to the hospital. “It's an unintended consequence of the way ambulance reimbursement has evolved,” said Dr. Sasson. “It is setting up a system to fail. What we are trying to do is get this information into the hands of people at the Centers for Medicare & Medicaid Services.” The best out-of-hospital care means staying on the scene and trying to get a pulse, she said. If that does not happen, then the patient should not be transported.
- ▪ State legislators and some EMS agencies have passed laws or policies mandating transport to the hospital, she said. Even if terminating resuscitation outside the hospital and do-not-resuscitate orders are possible, they are sometimes limited by narrow guidelines. This makes implementing national termination of resuscitation guidelines impossible, she said. That implementation of a national do-not-resuscitate registry “resonated with many EMS professionals as well as many professionals in the emergency department,” she said. “We provide all this unnecessary care to people who have made it clear that they do not want it. We often have to go against what they want because we are lacking that one little paper.” Often, she said, it is difficult for families to say stop once a tube is placed in their loved one's throat.
- ▪ Public perception, often buttressed by images in the media and in television entertainment, stands in the way of terminating resuscitation when it is the humane and medically sensible action. “From what people see on television, they believe all that stuff really happens in the hospital,” she said. “That's not reality. It's the number one thing that we need to do, get that across.”
Sometimes, Dr. Sasson said, it is difficult for paramedics to talk to families who have stood by stunned after they used all their skills but fail to revive a patient. In Michigan, she said, she has worked with paramedics to give them the tools to tell family members that they are ending the resuscitation and that the patient is not going to start breathing again.
“Paramedics sometimes think it is easier to transport the patient than to provide the support services the family needs,” she said. “In Seattle, they have a program in which volunteer chaplains serve as a support services team. The paramedics can call and say, ‘We terminated resuscitation in the field. Can you come to address the issue and provide grief counseling for the family?’ It's one of the biggest barriers that Seattle has been able to overcome.”
“Heroic efforts are an exercise in futility,” said Arthur Kellermann, MD, MPH, a professor of emergency medicine at Emory University School of Medicine and an associate dean for health policy. “Bringing a patient in the door of the emergency room with ongoing CPR following an unsuccessful resuscitation is just that. Patients don't do well, even if we achieve resuscitation. If we resuscitate in the emergency room, they all die in the ICU. Survival is less than 0.5 or 1 percent. What are we doing?” he said. “Rapid transport to the hospital cannot substitute for prehospital care, which is the most powerful predictor of survival. That kind of transport endangers the paramedics in the ambulance and the driving public. It pulls health care workers away from other patients to take on an ongoing resuscitation that is guaranteed to end in the death of the patient.
“I used to want to say to the paramedic: ‘I don't even want you to think about running to the hospital without getting a pulse back. If it doesn't happen there, even with high-speed driving, it won't work in the ER,’” said Dr. Kellermann, a senior author of the study.
The aftermath of resuscitation is another issue, he said. “Even if you can't save the patient, you can have a profound impact on the survivors. People are nervous about pronouncing an arrest in front of grieving family members. It needs to be done with sensitivity and compassion for the family. Sometimes, it's not.”
Bringing this issue to the fore and finding a way to establish national guidelines or rules for terminating resuscitation is not only humane, it is money-saving. “The moment some insurance executives realize that it's costing several thousand dollars to pursue a futile resuscitation in the emergency room, that will change,” said Dr. Kellermann.
Dr. Sasson agreed, saying that this contributes to skyrocketing health care costs. “There are people with treatable conditions who we can't provide care for because we are trying to resuscitate people we can't [save],” she said.
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