Waldrop DP, Clemency B, Maguin E, et al. Preparation for frontline end-of-life care: Exploring the perspectives of paramedics and emergency medical technicians. J Palliat Med. 2014;17(3):338—341.
The EMS Science
In a survey of 178 prehospital providers (76 EMT-Bs and 102 paramedics), respondents were asked to determine how they learned to interpret and follow do-not-resuscitate (DNR) and medical orders for life-sustaining treatment (MOLST) forms. The MOLST form is similar to the physician orders for life-sustaining treatment (POLST) used in over half the states in the nation.
Participants were given a survey with 37 multiple-choice questions where they were asked to identify the source of their education on DNR/MOLST and rate how confident they were in interpreting the DNR/MOLST. They were also asked one open-ended question asking what should be done to prepare EMS staff to deal with end-of-life calls.
The responses indicated that 92% (163) and 72% (128) received education on DNR and MOLST respectively through formal education, the vast majority of which was initial or refresher courses. A total of 77% (137) and 76% (135) obtained additional training through experience with DNR and MOLST forms. Only 38% (67) learned about DNR and MOLST from self-directed learning such as journals and the Internet.
Also of note was that 93% (165) of EMTs and 95% (169) of paramedics felt confident with interpreting a DNR, but only 91% (161) of EMTs and 84% (149) of paramedics felt confident interpreting a MOLST.
Medic Karen Wesley Comments
Just as EMS reflects life and family in so many ways, it’s not surprising that end-of-life issues are often uncomfortable and challenging. Being placed in the role of the final provider gives way to uncertainty in respecting the patient’s wishes, consoling family members, and the legal aspects of DNR and other end-of-life care documents.
There’s clearly an education piece missing to develop confidence in an EMT’s interpersonal skills and the ability to interpret legal orders while under the emotional stress of providing care to a dying patient.
I’ve often wondered why we’re shorted this training. We dedicate many hours annually to weapons of mass destruction (WMD) training while often spending no time at all on end-of-life care. WMD training is important, but the potential for WMD contact is remote compared to the surety you’ll be called to care for a terminal patient. Not to say that it isn’t important, but the end-of-life of our patients is a certainty that shows its face every day.
It’s difficult for some providers to deal with the sadness that occurs in our workday. These people tend to look to their partner to deliver the “news” of the death of a patient. When they have to do it, the anxiety of the situation creates stressors: “I never know what to say,” or “I wish I could’ve done something.”
Can we educate and train our providers to deal with end-of-life calls? I believe we can. I think it’s the responsibility of educators and mentors to help providers through these calls so they can move on and accept the outcome.
Is the answer to add more hours to training? I don’t think so. I think it requires a better use of the hours set for training and continuing education.
Why are the end-of-life forms so difficult for providers and caregivers to interpret quickly and effectively? The emotional aspects are intrinsic, easy for some and not so easy for others. The legal aspects are extrinsic. They’re specific for each state, and therefore should be addressed respectively in training. Adequate time for scenario-based training with the use of these forms is crucial to real-life application in time-sensitive situations.
Doc Keith Wesley Comments
I suspect few of our readers are surprised by this study. While it’s not a rigorous scientific paper, it does raise several serious issues that service and medical directors should consider when making policy and approving education.
First, no end-of-life policy is effective if it’s not coupled with a strong commitment to community education. It’s amazing how much time we spend getting citizens to perform bystander CPR, but there’s usually no effort made to ensure nursing homes and hospice programs are fully prepared to honor the dying patient’s wishes by having clear and concise end-of-life forms readily available. Just as bystander CPR significantly improves cardiac arrest survival, the misinterpretation of end-of-life wishes results not only in poor patient care, it demoralizes our EMTs and paramedics by making them feel like they’re having to make decisions that should’ve already been made.
Secondly, although the options are very clear when the end-of-life form is present, our providers need continuing education on how to interact with family members and other medical staff who may not fully appreciate the patient’s desires.
And finally, there are many ethical dilemmas our staff faces on a daily basis when confronted with end-of-life care. What do I do if the patient dies during transport? What if the patient has attempted suicide? Does the DNR take priority? These are just a few of difficult questions that place huge burdens on EMS clinicians.
At the end of the day, it’s the responsibility of EMS management to provide our staff with the tools to care for all patients–including those who want to die with dignity.