This article is meant to spark a discussion on a case that we may all face at one point or another.
The article does not represent Canadian Paramedicine’s point of view nor that of its representatives.
Feel free to send your opinion on the questions at the end of this article to firstname.lastname@example.org and we will publish some of the answers received.
The collision of poor family dynamics with the grind of prolonged caregiving puts the paramedic service in a challenging situation. What does decision-making capacity mean when a patient is palliative? Where best does medical oversight lie in the healthcare system? What resources are available to service providers when a family is tired and fractured?
One Friday afternoon early in the new year, dispatch received a 911 call from a palliative care nurse in the home of a client. A seventy-year-old woman (“Sharon”) with brain metastases had been receiving palliative care in her grandson’s (“Greg”) home since June. Previously, Sharon had been living with her daughter until her daughter had kicked her out. Greg’s wife (“Patty”) is a Personal Support Worker. She had been caring for Sharon with the support of palliative care nurses who visit three times a week.
When the nurses had arrived for their scheduled visit, Sharon and Greg were arguing. He told his grandmother that she would have to leave the house that afternoon. Patty reported that caring for Sharon had become impossible over the past few weeks. The night before, Sharon was up in the middle of the night, shouting for her smokes. When the nurses suggested to Sharon that it was time to move out of Greg and Patty’s home, she refused repeatedly. At that point, Greg became so angry that he left the home to go for a drive. The nurses called 911.
Paramedics “Len” and “Sara” arrived and spoke with Patty and Sharon and the nurses. Sharon was still refusing to leave the home. Len stepped outside the home and called the Commander, “Alison”. Alison wondered why the palliative nurses had called 911, given that the patient had capacity and was refusing to leave. The paramedic crew would have very limited means to deal with this, other than trying to persuade the patient that they could take her to a local hospital. Alison was also concerned that the social complexity of this call would better suit a community paramedic, given their more flexible schedule and ability to follow up. She also wanted to maintain the force’s ability to maintain 911 capacity in the local area.
Sharon would be effectively homeless if her grandson Greg maintained that she had to leave. The paramedics could only move her against her will, if the police became involved and stated that she was a danger to herself or others under the Mental Health Act. Alison wanted to ensure that alternative measures were put in place to ensure the safety of all involved. Alison worried that Sharon should not be sedated if she had the capacity to state her wishes.
Alison saw that a Community Paramedic, “Bob”, was working in the area, and asked him to attend the home as extra support. She then decided to attend the home herself as both she and Bob are Advanced Care Paramedics.
Alison arrived at the address to be greeted by Sara. Greg had returned to the home. Bob had arrived on scene and tried to speak with the family. Sharon was still refusing to leave the home. Greg was getting more and more aggressive, and had almost taken a swing at his grandmother, so the paramedics called the police.
When Alison entered the house, it was quiet. Greg had gone upstairs. His wife Patty spoke with the police officer who had just arrived. She stated that she was completely burntout from caring for both Sharon and Greg. Greg had had four strokes in the past year with significant personality change. He had a history of substance abuse. Patty made a few remarks (“sorry about the icy walkway. I am not allowed to use the snowblower” and “I ‘m too busy to have friends”) that led Alison to believe that Patty was at risk of domestic violence.
As the police officer spoke with Sharon and Patty, the healthcare providers gathered in the kitchen. The nurses told the paramedics that they carried a palliative care symptom relief kit that included midazolam. They reviewed Sharon’s current medication, stating that she was highly tolerant of various pain medications. She was a regular high-dose user of diazepam and was on a pain pump of hydromorphone for the cancer-related pain. Alison asked if they had been in contact with the family doctor for a medication order. If the nurses were able to administer a medication, it would better as the family doctor was the most appropriate clinician to oversee any sedation.
Alison was concerned that, as the call remained a 911 call, any medical order would have to be a patch call to the Base Hospital Physician. Paramedics are not part of a provincial college and must work under the medical oversight of doctors assigned to their program. The patch call would connect to an urban doctor working in the Emergency Department of a major hospital. The paramedic would describe the complex situation and advocate for a medical order. The doctor may or may not grant the paramedic request.
The palliative care nurse reached the family doctor by phone and was given a verbal order to administer five to ten milligrams of midazolam every thirty minutes as required. The doctor directed that the patient then be taken to hospital via ambulance. This medical order from the family doctor removed the paramedics advocating for a difficult decision, not routinely under their purview. The patient and family members, while still at an impasse, were calm. Alison assured the police officer that the situation was not going to escalate, and the officer left the house.
The nurses and paramedics had, in their turn, spoken to Sharon about moving to another location. If she didn’t leave that day with the paramedics, the police would have to arrest her. The patient continued to state that she did not want to leave.
In the kitchen, the paramedics and the nurses discussed which of two local hospitals to take Sharon to. Both had hospice units nearby, but Sharon’s smoking would prevent her from being admitted to either unit. As it was late Friday afternoon, the group anticipated that Sharon would be admitted into the hospital, but no other services could be considered until the following Monday. The group settled on taking her, sedated and by ambulance, to the smaller hospital in accordance with the orders from Sharon’s physician.
The palliative care nurse administered five milligrams of midazolam. This drug would relax her sufficiently to be taken out of the house on a stretcher. It would also have a mild amnesiac effect. Fifteen minutes later, the nurse administered a second dose of five milligrams. She administered a dose of ten milligrams thirty minutes later. The nurse also administered a bolus of hydromorphone via her pain pump. The patient nodded off ten minutes after receiving the hydromorphone. The healthcare providers were amazed at her tolerance.
The four paramedics moved Sharon onto the stretcher. She woke up but was silent. As they loaded her into the ambulance, Alison looked into Sharon’s eyes and saw defeat. Alison felt that Sharon’s entire life had been characterized by struggle. Being removed from her grandson’s home was a final loss.
All four paramedics drove to the selected hospital. Upon arrival, Alison went to register Sharon. The paramedics handed over Sharon’s medications and the handwritten binder of palliative nurses’ documentation. Bob explained Sharon’s story to the ER nurses, including the fact that she was effectively homeless. The paramedics noted the dysfunction they had witnessed. They stated that there were significant safety concerns, including the risk of ongoing domestic violence.
The admitting nurse stated that the new EMR made it difficult to document the additional information that the paramedics were relaying. It was agreed to identify Bob as the Community Paramedic involved and to add his work cell phone to the admitting record. Some of the complexity of Sharon’s case might be lost in the way the transfer would be documented, so Bob’s contact information was important.
The paramedics brought Sharon in and gently transferred her into a hospital bed. They then held an informal debrief in the hospital parking lot. They discussed how the family dynamics made this such a complex case. Len and Sara felt that the only thing they would done differently would be to call the police in earlier, as the grandson’s anger escalated more quickly than they expected. They realized that the hospital staff might feel that they had “dumped” a problem patient. However, they were relieved that Sharon was in a safe place.
Case Study Questions
- What, if anything, could have been done differently by the paramedics or by the palliative care nurses?
- Discuss the issues of patient capacity and decision-making in this scenario. Was the sedation of the patient handled ethically?
- List the system barriers in this scenario. What impact did they have on the paramedics’ ability to best serve the patient?
- Have you experienced a similar situation? How did you handle it? What did you learn from it?