By Peter Stebinger
It’s a small town. The volunteer fire department was and is the largest organization. We are the first responders and the medical transporters. As volunteer firefighter/EMTs, we were occasionally called to do welfare checks on the elderly and chronically ill. And sometimes we had to deal with an individual’s medical decision we disagreed with.
These calls would come in through 9-1-1, and we would be dispatched at a low priority. The request was usually from a family member, asking us to check in on and evaluate the health of an elder or chronically ill person. Sometimes, they wouldn’t have heard from the person in a long time. Sometimes, they just didn’t like what they heard on the phone. We would be dispatched to go out and see how they were.
And being a small town, our agent for the elderly also happened to be a volunteer EMT with the fire department. This was good news, as she worked in town and the town was generous in letting her respond to ambulance calls; provided she got her town related work done. And since, in another part of her life, she had been a paramedic with an urban-based service, she had a lot of experience and great skills.
Arriving on Scene
We would go up to the firehouse, get the ambulance and head over to the address with no lights or siren. The first assessment upon arrival is the exterior. Rarely would the lawn be mowed. Plants were often blocking the windows. The cars were never fancy and sometimes looked non-operational. The walk to the most used door was usually clear, often the side or rear door. Front doors are for guests.
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We would politely knock on the door and often a very feeble voice would invite us to come in. Occasionally, we would be admitted by another family member, who would wonder why we were there. We would explain that we have been asked to check on the health of the elder or patient or family member who lived in this residence.
Frequently, we would find the elder sitting on a couch in a home that was not very clean. These folks were usually frail, thin and not that great at ambulating. As per protocol, we would take all the baseline vitals, ask about medical history and medications and ask if they were in contact with regular medical care. And sometimes the answer would be yes and sometimes the answer would be no.
On a welfare check, cognitive impairment is as important as baseline vitals. While this is not technically an emergency, assessing thinking can tell a first responder a lot about general health. The conversation might range over a number of topics, who is doing the shopping, who drives for you if you are no longer driving, are you keeping up with the news in town, who visited you last? Are you sad, depressed, worried about safety? Is anyone else living here?
On a couple of occasions, we checked the refrigerator and cupboards to make sure there was food. Ramen, mac and cheese, cookies and soda. Microwave cooking is easy.
Often, we would find symptomology that none of us was thrilled about. It usually fell into the category of general weakness. And we’d ask the patient if they wanted to go to the hospital and almost always, with a very few exceptions, they would say no.
Know When and How Your Patient Can Legally Refuse Care
And then we would tell them that their health wasn’t that great and it would be good for them to be evaluated by medical professionals and that the professionals at our local hospital were very nice. Being in a medically well-resourced area, we would also say that there were many hospital options and if they didn’t want to go to the great big hospital in the nearest metropolitan center, they could go to one of the smaller hospitals serving one of the smaller communities which were just as close.
And almost always they would again say no.
Passed the Tests
Since they were competent, coherent and could pass most reasonable cognitive tests, they had, after all, given us their medical history, their birthday, and what medications they were taking, and answered all of our other questions reasonably, we would say some version of “thank you, call if anything changes; we are always available to bring you to medical care if you need it,” and then we would leave.
From time to time, other members of the ambulance service would look at our agent to the elderly and sometimes they would look at me as well, because I am also an ordained Episcopal priest, and as such we were both mandated reporters for elderly abuse, and say something like, “that person is frail, they’re sick, the people who are taking care of them aren’t doing a good job, and we need to take them to the hospital and you need to report elderly abuse.”
Our agent for the elderly would look at them and say: “They are competent by any legal definition to make these decisions for themselves. I see no sign of acute neglect. Needing to take a shower or maybe eat a more balanced diet or possibly get some exercise, are not by themselves signs of abuse.”
She didn’t need to add that when there were clear signs of abuse she had and would report to the state. On a couple of occasions, she had not even left the home before the state crisis intervention team had arrived.
Our colleagues, helpers and problem solvers all would say the patient needs to do all these things in order to live longer. And our agent for the elderly would reply: “That may be true, but people are allowed to make life-shortening decisions for quality-of-life reasons.
Clearly this patient believes that living in that home and the circumstances that they’re in is the life they want to live. They are surrounded by the things they know, the things they love and are being supported by the people they know and the people they love. I will not be filing a report with the state.”
And once or twice, when another firefighter was really upset she added: “As an EMT, you can file such a report with the state police should you so choose.” And no one ever did.
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I am older now and still respond to situations where I am asked to evaluate elders for abuse. And I sat with families as we loaded elders onto the helicopters to get them to places that were safer as their family members cried, because they weren’t sure that their elders would ever be able to return home. And we were not sure either.
And I know there are many instances of elderly abuse and neglect in our society and we all need to be on the watch for them.
Conclusion
I also strongly believe people living in stable situations, with the cognitive ability to make personal choices, may make decisions that I disagree with, even ones which may lead to a shorter lifespan, because that is what they want.
It can be very frustrating for EMTs and paramedics, who are very action and solution-oriented, to walk away from a situation that they feel they could make better. We operate so often under implied consent that we think that’s the only way situations can be resolved. But at the end of the day, we are not the ones who can finally make decisions for others.
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And I believe and trust that people will consistently make the best decisions for themselves, when given the best possible information. Our job is to give them the best possible information, and then live with the patient’s decision.
Editor’s Note: This commentary reflects the opinion of the author and does not necessarily reflect the opinions of JEMS.
About the Author
Peter Stebinger is a chaplain for the CT1 Disaster Medical Assistance Team for the Department of Health and Human Services National Disaster Meical System. For over 30 years, he was an EMT/firefighter and chaplain when needed for a smalltown volunteer fire department in Connecticut.
