With the help of Compassion and Choices, the family of Emily DeArmond has filed an action against Kaiser Health Plan seeking monetary damages and an order that Kaiser institute policies to ensure that their providers respect patients’ treatment instructions.
Emily DeArmond lived with brain cancer for most of her young life. As she approached her final months, her parents met with her oncologist, her neurosurgeon and a medical ethicist to discuss Emily’s care in light of her rapid decline. Together they completed a POLST.
Several weeks after completion of the POLST, Emily’s parents found her unconscious in bed. They rushed her to a nearby emergency room affiliated with Kaiser, Emily’s provider. They told the staff about her POLST, which included the order: Do Not Intubate. They did not want Emily to endure any painful, invasive procedures in her final days. But the emergency physician failed to honor the order and forced a breathing tube down Emily’s throat. She endured the presence of the tube until she was transferred to another Kaiser facility, where doctors withdrew it and allowed Emily to die.
While there are other pending lawsuits concerning resuscitation in contravention of DNR orders and advance directives, this may be the first lawsuit for failure to comply with a POLST.
16 comments:
I find it sad that the family rushed her to the ED when her end was so clearly near. If she was DNI but NOT DNR I can see that the physician was conflicted, as well, although that does not make his refusal to follow the stated refusal of certain interventions excusable. But I also wonder what the family thought the ED could do for their child.
Hospice, hospice, hospice.
Why are there always so many lawsuits for failure to comply with advanced directives --and now a POLST and NO lawsuits for the unauthorized placement of DNR code status (No CPR)in hospital charts?
Personally, I think the POLST and MOLST directives are dangerous in that paramedics in the 911 ambulances will be given the authority to permit patients to die in these ambulances because of the DNR status the patient has pre-selected when they were in good health.
Emergency physicians who are trained to save the life of the paient and who are generally on contract don't have the time to read a POLST document. They shouldn't be required to take the time to read it in fairness to all of the other patients in
Emergency who do want to live into the next day.
The culture of death is supported by these forms. Recently, my City had to pay a settlement to a family when the fire department paramedics permitted a patient to die in the ambulance. In fact, they didn't know he was dead until they got him to the hospital.
I have found the paramedics to always be very competent and attentive and interested in saving the life of the patient and I wondered if, perhaps, this patient had elected DNR status prior to his last ride in the ambulance.
I will post a link to the Complaint. Usually, the family panics when the patient exhibits distressing symptoms. Usually they just want pain and symptom relief.
I agree with SuesquatchRN. It's not right to send a terminally ill person home with a plan to not intubate/resusscitate, but no support or plan for what to do when the person dies. Hospice is the answer for this situation. They are the alternative to the emergency room. Sadly, this family was not given the resources to cope, and hospice would have been the way to go. The ER is not equipped to provide comfort care.
Sheila Grant, RN, BSN, CHPN
Hi Dr. Pope, I'm the ED of Children's Hospice & Palliative Care Coalition we are, with funding from CA HealthCare Foundation, developing a curriculum for use of POLST in pediatrics. I would be very interested in learning more and following this case as it moves forward. Do you have any more details on the case, ie Emily's age, city, state. Thank you, @DevonDabbs
1. I think points out the difficulty of combining your Hospice and Home Health organizations. They may do similar things, but they are different mind sets and it is hard for the home health nurse to make the appropriate transition.
2. Why can't E.R.s be set up to perform a Comfort Code, as easily as they can a Cardiac or Stroke code?
1. I think points out the difficulty of combining your Hospice and Home Health organizations. They may do similar things, but they are different mind sets and it is hard for the home health nurse to make the appropriate transition.
2. Why can't E.R.s be set up to perform a Comfort Code, as easily as they can a Cardiac or Stroke code?
Under the law, nobody can be forced into Hospice and Palliative Care where it is assumed the patient will not use the Emergency Room and will die peacefully at home with the help of drugs provided by HOSPICE.
But, of course, you can elect to go on Hospice and still, at any time, leave Hospice and use the Emergency room, as is your right under existing law.
The child was unconscious and would, no doubt, have died at home if they hadn't taken her into Emergency. But, what a tough decision for the parents who didn't want to assume the responsiblility and make the decision to end her life at that time.
I don't think they have a case because they negotiated the POLST and knew the terms --and did they want her to die in Emergency instead of at home? She most certainly would have died if the Doctor hadn't intubated her. Is this what they wanted? And are they claiming money damages because of the intubation which extended their pain and hers?
But, perhaps this case will illustrate to the courts that under the existing law, even if physicians/hospitals get informed consent to DNR/DNI/ palliative care and hospice, etc.., the Emergency Rooms are not going to accept oral POLSTs and will keep the patients living for another day because this is their mission under the law.
Are there any conditions under which we don't want our Emergency Rooms to do their best to keep patients alive? Will the paramedics be delivering dead patients to the hospitals because of POLSTs?
Under existing laws, the POLSTs can be "orally" rescinded at any time? ---in the hospital or in the emergency room.
The conflict between the two laws "The Right to Live" and The Right to Die" may have to be solved by the courts but I personally hope the courts will decide for the premacy of The Right to Live and that that Emergency Rooms will always be mandated to save lives.
The real crux of the problem is that as much as everyone wants to hope and believe that hospice care for pediatrics is as equal to hospice for adults, apart from a few exceptions, this just isn't true. The adult model just does not work. It seems like there are different models of care for adults vs. pediatrics in every other area, yet why not hospice. It's time for major change in how we care for children that are dying. - an experienced and bereaved parent, involved with FAC of CHPCC
Of course the simple answer is "hospice", but unfortunately the bigger issue here is that as much as we would like to think that the adult hospice model translates easily to children, that is just not true. The adult hospice model should only be used as a starting point. Change is needed in how we care for our dying children. Could we be so bold as to come up with a new term to describe this care. The death of a child is contrary to the natural order of life, yet we are still using the same term, an therefore the same type of model of care as we do for adults. Re-framing our approach and working with parents who have experienced their child's death is key to this change. We have a long way to go, but a better system is an imperative. - Jim S., FAC of the CHPCC
Anonymous:
Why not law suits for "unauthorized placement of DNR code status"?
Whether or not CPR is an appropriate therapy is a medical decision. In most, if not all communities, it is the standard of care when a doctor thinks a disease process is fatal, he/she tells the family that the patient is at high risk of dying, and puts a DNR order on the chart. The patient and family determine the goals of care, but whether any given treatment is appropriate to further those goals, a medical decision. It would be considered inappropriate, and medically libelous to perform CPR on a patient that has no hope of recovery.
I guess I would have concerns about the quality of the paramedics in your city if they were unaware that their patient had died.
Suesquatch: I agree with your concern regarding confusion over DNR or DNI. It may sometimes make sense to intubate a COPD/Asthma patient urgently, but not to do CPR. It never makes sense to do CPR without intubation. With rare exception, I tell families that we are really talking about ACLS, and it is all or nothing. In fact, I think it would be better to use the term ACLS, or No ACLS, rather than Code/Nocode, or DNI/DNR.
Antinyx: We all approach this matter from our own perspective ---but what matters is the perspective of the law.
Physicians do NOT have the legal right to put unauthorized (by patient or legal surrogate) DNR/DNI code status into hospital charts.
Because "medical futility" and "fiscal futility" are related and cannot, in reality, be separated, the unilateral DNR/DNI is very dangerous to elderly patients.
You indicate that "It would be considered inappropriate and medically libelous to perform CPR on a patient that has no hope of recovery."
If this were true, it would, and should, then, be considered inappropriate and medically libelous to treat patients in the OUTPATIENT setting who have no hope of recovery." But, this, of course, would cut profits!
The HOSPICE model is not appropriate for children because the primary caretakers, the parents, must be spared the additional agony of feeling complicit in the "planned" and "premeditated" death of their child.
Anonymous: I agree that an adult hospice model doesn't work for pediatrics. Pediatrics needs a special program.
As to CPR: I want to acknowledge that there are times when the potential outcome is not clear. In that case an axiom in medicine is, "Always give the patient the benefit of the doubt". There are other times, in the case of irreversible organ damage when there is no doubt.
Sometimes medical students are accused of having a "God complex", but one of the first things you learn after graduation, is that there are times when no amount of Intensive care, no amount of drugs, no surgery, chemotherapy, ventilator, CPR or "resuscitation" or even prayer will keep a person alive. In times like this, CPR will not help and it can do incalculable harm. It can rob families of the opportunity to say last words. It will turn a peaceful death surrounded by loved ones into a violent death where loved ones are excluded and traumatized. Increased PSTD in families not given access to hospice is well documented.
Laws are different in different states, so I don't know what the laws are in your state and I could be wrong, but as far as I am aware there is no state that requires medical personnel to perform CPR in such circumstances.
The appropriate, compassionate treatment in such cases is to be honest with the family and to help them through their grief.
Your strong feelings come through in your posts. I wonder, have you been in, or are you afraid that you might someday be in a situation where you or a loved one might not be given the benefit of the doubt?
Correction: libelous is the wrong word, negligent is a better word.
I would also like to address a common misunderstanding. Sometimes people think that giving pain medications to dying patients may hasten death. It is now well documented that hospice patients, who generally receive better pain control, live much longer, (on the order of 3-6 months) than patients who don't receive hospice. That is probably due to decreased stress and improved family support.
Also, when it comes to treating the elderly in the hospital, it is shown that the incidence of post op delirium in inversely proportional to the amount of narcotic they are given. In other words, it is pain that causes delirium, not pain medications. In my experience there is nothing that is more deliriogenic than uncontrolled pain.
The matter of "pain" is another subject matter. Pain, of course, is a natural human response and a warning that reinforces the human's natural instinct to fight to live and to defeat death.
The pain of child birth, in past times, was always said to be "good" pain because it resulted in new life and perhaps greater love of Mother for the child -- because of the investment in pain??
I don't think Hospice is a good solution for the death of children. The parents would feel complicit in the death when they administered pain relieving druga, etc.. There has to be a better way to help the parents and the child.
However, when the fight becomes "medically" futile and fiscally punishing to the hospitals, and to the system, the referee needs to step in and end the fight.
But, should the referee be the Courts or some "neutral" and unbiased non-political body OUTSIDE of the hospitals whose opinions are respected and binding?
To Anonymous:
This is a false dilemma, because many studies show that patient's on hospice live longer, and that controlling pain extends life. The solution in not a referee, but education.
Also, in the elderly, delirium in inversely related to the amount of morphine given for post-op pain. i.e. more morphine means less pain and less delirium.
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