Guest guest Posted September 18, 2006 Report Share Posted September 18, 2006 MIKE, you should be writing law school exams! That's a great scenario you present. I'll wade in, but I'll tell you in advance that I don't know the answers. GG Read down, pleeze. > > So, to misquote Clinton, doesn't that depend on what your definition of " is " > is? In this case the patient can be very clearly clinically dead - even to > the point of signs incompatible with life. But, until legally dead as > declared by a physician or JP, the law considers them alive. > Yes. Legally dead and clinically dead are two entirely different things. For example, X disappears in Lake Michigan (to reference a recent case on Greta's show) and his body cannot be found. He's still alive until declared legally dead. On the other hand, a patient dies enroute, and that patient is clinically dead but not legally dead because, in Texas at least, EMTs of any level cannot pronounce a patient. Only a physician, medical examiner in those few counties that have them, and JPs in the rest, can pronounce death. Now, of course, that's ridiculous on its face because JPs do not normally have any medical training whatsoever. I have had many JPs ask, " Gene, is he dead? " To which I reply, depending upon how much I like the JP, either " Yes, " or " I have no idea. " When you say " I have no idea, " it's fun to watch what happens after that. > > So, here's how I'd search for case law on this... let's say that has a > DNR and dies in the back of my ambulance, but I keep going to the hospital, > which is 60 minutes away. lies on my stretcher for 60 minutes, turns > blue-gray, and starts pooling blood. > > I get to the ER, and 's neighbor, who hates with a passion, is > standing on the ER dock. When I open the doors, the neighbor steps in and > shoots in the head, exposing brain matter (an obviously fatal wound). > > Can 's neighbor be arrested for murder? Did he in fact commit murder > because was legally, but not clinically, alive? Or, did he tamper with > a corpse? Which " death " matters? Which is legally challengeable? > That's one of the best law school questions I have heard in a long time. The prosecution would have to show that he was " alive " at the time of the shooting, and the defense would show that he was " dead. " I admit that I have not researched this, and, unfortunately, I really don't have time to do it, but maybe somebody on here who is in law school will. I will say that I've never read a case that addressed this issue. > > > Another scenario - under current Texas criminal law if I shoot a pregnant > woman in the head and kill her then I can be charged with her death and with > the death of her fetus - two counts of felony murder. I would wonder, > though, how easy it might or might not be to challenge whether or not the > fetus was clinically alive at the time of the mother's murder... because > fetuses die and women miscarry " all the time " , right (statistically enough > to raise as a defense, I'd guess)? How do you " prove " that someone who is > not very obviously dead was actually alive at the time of the perceived > cause of death absent solid forensic (forensic pathology) signs? > I think this would depend upon the Medical Examiner's opinion. If I am not mistaken, forensic pathologists can determine whether or not a fetus was alive or not at the time of the mother's murder, but I may be wrong. Drs. Wecht and Baden, where are you? > > If there are answers to these questions in case law, then you could likely > extrapolate whether clinical death == legal death in certain circumstances, > then try to apply that precedent to EMTALA laws. > Mike, you've outdone yourself. These are very interesting questions. To my knowledge, the statutes do not provide clear guidance, and neither do the cases. > > Just my strange, twisted, random take on this... > > Mike > > I think this issue is one that is not adequately addressed by Texas law at this time. I'm going to ask Maxie to think about (1) asking for an AG's opinion on when death occurs, and (2) considering the possibility of formulating a statewide protocol, through regulation, that would guide us through these processes. Thanks to all who have responded to my inquiry. This is a thorny issue. The hospitals do not want to receive patients through the ER that are clinically dead and not being resuscitated, as happens when a patient with a valid OOH DNR codes enroute, and the EMS services do not want to be sitting on the side of the road with a dead body waiting for a JP to come and pronounce the deceased and allow the body to be transported to a mortuary. We need some carefully thought out guidelines. I would like very much to know what Houston EMS and Dallas EMS do about these cases. Of course, there are practically no medics from either system who respond to this list (a pet peeve of mine) so we have no input from them, but maybe somebody like Kenny Navarro or Dr. Fowler or Dr. Persse (who may be lurking) can tell us what they do. I want to know what to do when I'm half way between Abilene and Fort Worth with a patient who has a DNR and dies enroute and I don't have a clue what county I'm in. Do I call 911 and ask for LE, or do I call the transferring hospital and try to get the transferring physician on line (fat chance) and see if he or she will pronounce the patient, or sit there on the side of I20 and wait for 3 hours for the JP, or what? Believe me, I've read Chapter 49 of the Code of Criminal Procedure, which deals with Inquests, and I don't find the answers to these questions. Gene G. > > > > > Gene, > > > > Isn't that an EMTALA violation? The patient isn't actually " dead " until a > > doctor or JP says he is, right? How can the hospital refuse to do a > > screening exam and stabilization on someone who hasn't been pronounced? > > > > Randy > > > > R. (Randy) Loflin, M.D., FACEP > > Associate Professor > > Medical Director, City of El Paso EMSS > > > > > > Death enroute with DNR > > > > > > Let's say that you're transporting a patient with a valid out of > > hospital > > > DNR > > > to the hospital and that you are half way there, on the highway, when > > the > > > patient dies. What do you do? Stop, call for a JP, and wait for the JP > > to > > > arrive? Continue transport to the hospital? Turn around, take the > > patient > > > back where you got him, and call for the JP there? Call the treating > > > physician > > > and ask him to pronounce? > > > > > > Has anyone addressed this situation by protocol? And if so, will you > > share? > > > > > > I will appreciate any help. We need to develop a protocol for these > > > situations, and I have never thought about this before. Any ideas will > > be > > > appreciated. > > > > > > Gene Gandy > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 19, 2006 Report Share Posted September 19, 2006 Gene: You didn't ask about San but I can answer . First online medical control can be contacted so that CPR can be 'officially' withheld per the MD. The patient can then be taken directly to the ME's office (depending on time of day) OR to continue on to the hospital (the family is likely going to be there). This scenario has occurred in the past but I am not aware of the receiving hospital ever refusing a patient. The short transport times makes your scenario less likely for most of the urban systems. Lance Lance Villers, MA, LP Assistant Professor & Interim Chair, Department of Emergency Health Sciences The University of Texas Health Science Center at San 7703 Floyd Curl Dr. San , TX 78229-3900 ________________________________________________________________________ 1e. Re: Death enroute with DNR Posted by: " wegandy1938@... " wegandy1938@... wegandy1938 Date: Mon Sep 18, 2006 9:27 pm (PDT) We need some carefully thought out guidelines. I would like very much to know what Houston EMS and Dallas EMS do about these cases. Of course, there are practically no medics from either system who respond to this list (a pet peeve of mine) so we have no input from them, but maybe somebody like Kenny Navarro or Dr. Fowler or Dr. Persse (who may be lurking) can tell us what they do. I want to know what to do when I'm half way between Abilene and Fort Worth with a patient who has a DNR and dies enroute and I don't have a clue what county I'm in. Do I call 911 and ask for LE, or do I call the transferring hospital and try to get the transferring physician on line (fat chance) and see if he or she will pronounce the patient, or sit there on the side of I20 and wait for 3 hours for the JP, or what? Believe me, I've read Chapter 49 of the Code of Criminal Procedure, which deals with Inquests, and I don't find the answers to these questions. Gene G. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 19, 2006 Report Share Posted September 19, 2006 Lance, Thanks. That makes sense in your area. Unfortunately, in rural settings there is no ME's office, and the hospitals are--shall we say--not all on the same page as to what they will do. I think we need a statewide protocol for this, probably a regulation, and maybe some legislation. It's not a situation that occurs often, but it is something that has the probability of occurring at some time for every service. We don't need to be out here on our own trying to fashion guidelines where the law is so vague. I will ask the state to do something on this. Gene G. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 20, 2006 Report Share Posted September 20, 2006 Drop them by the local funeral home, I bet they would get it taken care of. P.S. Not really serious comment. Henry Re: Death enroute with DNR Lance, Thanks. That makes sense in your area. Unfortunately, in rural settings there is no ME's office, and the hospitals are--shall we say--not all on the same page as to what they will do. I think we need a statewide protocol for this, probably a regulation, and maybe some legislation. It's not a situation that occurs often, but it is something that has the probability of occurring at some time for every service. We don't need to be out here on our own trying to fashion guidelines where the law is so vague. I will ask the state to do something on this. Gene G. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 20, 2006 Report Share Posted September 20, 2006 I suppose we could go back to the days when the funeral homes raced each other to the scene to grab the bodies. That would mean that they'd have to get some souped up funeral cars, though. G > > Drop them by the local funeral home, I bet they would get it taken care of. > P.S. Not really serious comment. > > Henry > Re: Death enroute with DNR > > Lance, > > Thanks. That makes sense in your area. Unfortunately, in rural settings > there is no ME's office, and the hospitals are--shall we say--not all on the > same page as to what they will do. > > I think we need a statewide protocol for this, probably a regulation, and > maybe some legislation. > > It's not a situation that occurs often, but it is something that has the > probability of occurring at some time for every service. We don't need to be > out > here on our own trying to fashion guidelines where the law is so vague. > > I will ask the state to do something on this. > > Gene G. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 20, 2006 Report Share Posted September 20, 2006 The problem is that the hospital physicians won't pronounce them because they " don't know the cause of death. " Gene > > As you all may or may not know, the local ambulances used to be run by the > funeral home back in the days before paramedics. I know in Bay City the > local EMS was still dispatched from the funeral home as recently as 1987 and > still may be so. Also, in some rural areas there is no ME rather the local > JP serves as the coroner. I have also had, in the past, ME personnel come to > perform autopsies in the embalming room at the mortuary. I suppose it would > depend on the community and the circumstances involved. But in the scenario > I think I'd let medical direction dictate how I handled it. I would record > the time of death and continue on to the hospital ER so they can pronounce > death (DOA). Heck, the patient was alive when I left the scene with him and > died enroute to the proper medical facilities. The difference is that I have > a legal order signed by a physician telling me to withhold lifesaving > measures and it will probably tell you what you can or cannot do. Not to be > confused with an Advanced Directive which covers " long term care " such as > feeding tubes and the like. > > Two more of my copper colored tender disks!!! > > Jim > > > > >Reply-To: texasems-l@yahoogrotexasem > >To: <texasems-l@yahoogrotexasem> > >Subject: Re: Death enroute with DNR > >Date: Wed, 20 Sep 2006 07:57:15 -0500 > > > >Drop them by the local funeral home, I bet they would get it taken care of. > >P.S. Not really serious comment. > > > >Henry > > Re: Death enroute with DNR > > > > > > Lance, > > > > Thanks. That makes sense in your area. Unfortunately, in rural settings > > there is no ME's office, and the hospitals are--shall we say--not all on > >the > > same page as to what they will do. > > > > I think we need a statewide protocol for this, probably a regulation, > >and > > maybe some legislation. > > > > It's not a situation that occurs often, but it is something that has the > > probability of occurring at some time for every service. We don't need > >to be out > > here on our own trying to fashion guidelines where the law is so vague. > > > > I will ask the state to do something on this. > > > > Gene G. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 20, 2006 Report Share Posted September 20, 2006 As you all may or may not know, the local ambulances used to be run by the funeral home back in the days before paramedics. I know in Bay City the local EMS was still dispatched from the funeral home as recently as 1987 and still may be so. Also, in some rural areas there is no ME rather the local JP serves as the coroner. I have also had, in the past, ME personnel come to perform autopsies in the embalming room at the mortuary. I suppose it would depend on the community and the circumstances involved. But in the scenario I think I'd let medical direction dictate how I handled it. I would record the time of death and continue on to the hospital ER so they can pronounce death (DOA). Heck, the patient was alive when I left the scene with him and died enroute to the proper medical facilities. The difference is that I have a legal order signed by a physician telling me to withhold lifesaving measures and it will probably tell you what you can or cannot do. Not to be confused with an Advanced Directive which covers " long term care " such as feeding tubes and the like. Two more of my copper colored tender disks!!! Jim > >Reply-To: texasems-l >To: <texasems-l > >Subject: Re: Death enroute with DNR >Date: Wed, 20 Sep 2006 07:57:15 -0500 > >Drop them by the local funeral home, I bet they would get it taken care of. >P.S. Not really serious comment. > >Henry > Re: Death enroute with DNR > > > Lance, > > Thanks. That makes sense in your area. Unfortunately, in rural settings > there is no ME's office, and the hospitals are--shall we say--not all on >the > same page as to what they will do. > > I think we need a statewide protocol for this, probably a regulation, >and > maybe some legislation. > > It's not a situation that occurs often, but it is something that has the > probability of occurring at some time for every service. We don't need >to be out > here on our own trying to fashion guidelines where the law is so vague. > > I will ask the state to do something on this. > > Gene G. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 20, 2006 Report Share Posted September 20, 2006 QUESTION: Is not pronouncing someone dead strictly for the purposes of establishing the official time of death? I mean what does the cause of death have to do with the time they officially expired? Unless a post is done, nobody knows why someone died. I mean to me cardiac arrest is not a cause of death rather what caused the arrest is the cause of death. If they are going to refuse to pronounce because they don't know the cause of death then how can anyone ever be pronounced dead until an autopsy is completed. Just a thought. Jim >From: wegandy1938@... >Reply-To: texasems-l >To: texasems-l >Subject: Re: Death enroute with DNR >Date: Wed, 20 Sep 2006 22:15:16 EDT > >The problem is that the hospital physicians won't pronounce them because >they > " don't know the cause of death. " > >Gene >In a message dated 9/20/06 7:59:13 PM, TranquilityBase34@... >writes: > > > > > > As you all may or may not know, the local ambulances used to be run by >the > > funeral home back in the days before paramedics. I know in Bay City the > > local EMS was still dispatched from the funeral home as recently as 1987 >and > > still may be so. Also, in some rural areas there is no ME rather the >local > > JP serves as the coroner. I have also had, in the past, ME personnel >come to > > perform autopsies in the embalming room at the mortuary. I suppose it >would > > depend on the community and the circumstances involved. But in the >scenario > > I think I'd let medical direction dictate how I handled it. I would >record > > the time of death and continue on to the hospital ER so they can >pronounce > > death (DOA). Heck, the patient was alive when I left the scene with him >and > > died enroute to the proper medical facilities. The difference is that I >have > > a legal order signed by a physician telling me to withhold lifesaving > > measures and it will probably tell you what you can or cannot do. Not to >be > > confused with an Advanced Directive which covers " long term care " such >as > > feeding tubes and the like. > > > > Two more of my copper colored tender disks!!! > > > > Jim > > > > > > > >Reply-To: texasems-l@yahoogrotexasem > > >To: <texasems-l@yahoogrotexasem> > > >Subject: Re: Death enroute with DNR > > >Date: Wed, 20 Sep 2006 07:57:15 -0500 > > > > > >Drop them by the local funeral home, I bet they would get it taken care >of. > > >P.S. Not really serious comment. > > > > > >Henry > > > Re: Death enroute with DNR > > > > > > > > > Lance, > > > > > > Thanks. That makes sense in your area. Unfortunately, in rural >settings > > > there is no ME's office, and the hospitals are--shall we say--not all >on > > >the > > > same page as to what they will do. > > > > > > I think we need a statewide protocol for this, probably a regulation, > > >and > > > maybe some legislation. > > > > > > It's not a situation that occurs often, but it is something that has >the > > > probability of occurring at some time for every service. We don't need > > >to be out > > > here on our own trying to fashion guidelines where the law is so >vague. > > > > > > I will ask the state to do something on this. > > > > > > Gene G. > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 21, 2006 Report Share Posted September 21, 2006 Well, it is chicken*^$#, but as we all know, there are lots of chickens out there. There's not going to be any call for an autopsy except in questioned cases, because nobody is going to pay the costs. What does an autopsy cost these days? I have written Maxie Bishop and asked him to get us some guidance from DSHS on this. We may need some curative legislation, because there is clearly a gap in the law. When it was written, people dying in ambulances with DNRs hadn't been thought of yet. Some states allow paramedics to pronounce. That may be the solution in these isolated cases ONLY. Gene G. > > So, why not let them in and call for the coroner for autopsy. > > Even though they don't know the cause of death are they not familiar with > the dead body as it relates to the physical world? > > Sounds kinda chicken#% & @# to me. > > wegandy1938@wegandy wrote: > The problem is that the hospital physicians won't pronounce them because > they > " don't know the cause of death. " > > Gene > In a message dated 9/20/06 7:59:13 PM, TranquilityBase34@Tranquility writes: > > > > > As you all may or may not know, the local ambulances used to be run by the > > funeral home back in the days before paramedics. I know in Bay City the > > local EMS was still dispatched from the funeral home as recently as 1987 > and > > still may be so. Also, in some rural areas there is no ME rather the local > > JP serves as the coroner. I have also had, in the past, ME personnel come > to > > perform autopsies in the embalming room at the mortuary. I suppose it > would > > depend on the community and the circumstances involved. But in the > scenario > > I think I'd let medical direction dictate how I handled it. I would record > > the time of death and continue on to the hospital ER so they can pronounce > > death (DOA). Heck, the patient was alive when I left the scene with him > and > > died enroute to the proper medical facilities. The difference is that I > have > > a legal order signed by a physician telling me to withhold lifesaving > > measures and it will probably tell you what you can or cannot do. Not to > be > > confused with an Advanced Directive which covers " long term care " such as > > feeding tubes and the like. > > > > Two more of my copper colored tender disks!!! > > > > Jim > > > > > > > >Reply-To: texasems-l@yahoogroReply-T > > >To: <texasems-l@texasems-l@<wbr> > > >Subject: Re: Death enroute with DNR > > >Date: Wed, 20 Sep 2006 07:57:15 -0500 > > > > > >Drop them by the local funeral home, I bet they would get it taken care > of. > > >P.S. Not really serious comment. > > > > > >Henry > > > Re: Death enroute with DNR > > > > > > > > > Lance, > > > > > > Thanks. That makes sense in your area. Unfortunately, in rural settings > > > there is no ME's office, and the hospitals are--shall we say--not all on > > >the > > > same page as to what they will do. > > > > > > I think we need a statewide protocol for this, probably a regulation, > > >and > > > maybe some legislation. > > > > > > It's not a situation that occurs often, but it is something that has the > > > probability of occurring at some time for every service. We don't need > > >to be out > > > here on our own trying to fashion guidelines where the law is so vague. > > > > > > I will ask the state to do something on this. > > > > > > Gene G. > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 21, 2006 Report Share Posted September 21, 2006 That's true if the doctor is available. But what if the patient has moved into a nursing home miles away from where the original treating doctor was, and there's no new PCP who has written the DNR? GG > > I am pretty sure I heard somewhere, and I can' remember where because my > memory fails more than it works nowadays, that in these cases, i.e. DNR > patient expires of natural causes, that there doesn't need to be any sort > of autopsy, inquest, or investigation. The patient is under a Dr.s care and > the Dr. Who signed the DNR can sign the death certificate. > > > > -- Re: Death enroute with DNR > > > >Date: Wed, 20 Sep 2006 07:57:15 -0500 > > > > > > > >Drop them by the local funeral home, I bet they would get it taken care > > > of. > > > >P.S. Not really serious comment. > > > > > > > >Henry > > > > Re: Death enroute with DNR > > > > > > > > > > > > Lance, > > > > > > > > Thanks. That makes sense in your area. Unfortunately, in rural > settings > > > > there is no ME's office, and the hospitals are--shall we say--not all > on > > > >the > > > > same page as to what they will do. > > > > > > > > I think we need a statewide protocol for this, probably a regulation, > > > >and > > > > maybe some legislation. > > > > > > > > It's not a situation that occurs often, but it is something that has > the > > > > probability of occurring at some time for every service. We don't need > > > >to be out > > > > here on our own trying to fashion guidelines where the law is so vague > > > > > > > > > I will ask the state to do something on this. > > > > > > > > Gene G. > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 21, 2006 Report Share Posted September 21, 2006 So, why not let them in and call for the coroner for autopsy. Even though they don't know the cause of death are they not familiar with the dead body as it relates to the physical world? Sounds kinda chicken#% & @# to me. wegandy1938@... wrote: The problem is that the hospital physicians won't pronounce them because they " don't know the cause of death. " Gene > > As you all may or may not know, the local ambulances used to be run by the > funeral home back in the days before paramedics. I know in Bay City the > local EMS was still dispatched from the funeral home as recently as 1987 and > still may be so. Also, in some rural areas there is no ME rather the local > JP serves as the coroner. I have also had, in the past, ME personnel come to > perform autopsies in the embalming room at the mortuary. I suppose it would > depend on the community and the circumstances involved. But in the scenario > I think I'd let medical direction dictate how I handled it. I would record > the time of death and continue on to the hospital ER so they can pronounce > death (DOA). Heck, the patient was alive when I left the scene with him and > died enroute to the proper medical facilities. The difference is that I have > a legal order signed by a physician telling me to withhold lifesaving > measures and it will probably tell you what you can or cannot do. Not to be > confused with an Advanced Directive which covers " long term care " such as > feeding tubes and the like. > > Two more of my copper colored tender disks!!! > > Jim > > > > >Reply-To: texasems-l@yahoogrotexasem > >To: <texasems-l@yahoogrotexasem> > >Subject: Re: Death enroute with DNR > >Date: Wed, 20 Sep 2006 07:57:15 -0500 > > > >Drop them by the local funeral home, I bet they would get it taken care of. > >P.S. Not really serious comment. > > > >Henry > > Re: Death enroute with DNR > > > > > > Lance, > > > > Thanks. That makes sense in your area. Unfortunately, in rural settings > > there is no ME's office, and the hospitals are--shall we say--not all on > >the > > same page as to what they will do. > > > > I think we need a statewide protocol for this, probably a regulation, > >and > > maybe some legislation. > > > > It's not a situation that occurs often, but it is something that has the > > probability of occurring at some time for every service. We don't need > >to be out > > here on our own trying to fashion guidelines where the law is so vague. > > > > I will ask the state to do something on this. > > > > Gene G. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 21, 2006 Report Share Posted September 21, 2006 I am pretty sure I heard somewhere, and I can' remember where because my memory fails more than it works nowadays, that in these cases, i.e. DNR patient expires of natural causes, that there doesn't need to be any sort of autopsy, inquest, or investigation. The patient is under a Dr.s care and the Dr. Who signed the DNR can sign the death certificate. -- Re: Death enroute with DNR > > >Date: Wed, 20 Sep 2006 07:57:15 -0500 > > > > > >Drop them by the local funeral home, I bet they would get it taken care > of. > > >P.S. Not really serious comment. > > > > > >Henry > > > Re: Death enroute with DNR > > > > > > > > > Lance, > > > > > > Thanks. That makes sense in your area. Unfortunately, in rural settings > > > there is no ME's office, and the hospitals are--shall we say--not all on > > >the > > > same page as to what they will do. > > > > > > I think we need a statewide protocol for this, probably a regulation, > > >and > > > maybe some legislation. > > > > > > It's not a situation that occurs often, but it is something that has the > > > probability of occurring at some time for every service. We don't need > > >to be out > > > here on our own trying to fashion guidelines where the law is so vague > > > > > > I will ask the state to do something on this. > > > > > > Gene G. > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 21, 2006 Report Share Posted September 21, 2006 You missed the beginning of the conversation.....the discussion is about a DNR patient dying in the ambulance during transport to a medical facility and who is going to take responsibility for pornouncing him dead and all that legal mess. > >Reply-To: texasems-l >To: <texasems-l > >Subject: Re: Death enroute with DNR >Date: Thu, 21 Sep 2006 16:12:19 -0500 (Central Standard Time) > >I am pretty sure I heard somewhere, and I can' remember where because my >memory fails more than it works nowadays, that in these cases, i.e. DNR >patient expires of natural causes, that there doesn't need to be any sort >of autopsy, inquest, or investigation. The patient is under a Dr.s care >and >the Dr. Who signed the DNR can sign the death certificate. > > > >-- Re: Death enroute with DNR > > > >Date: Wed, 20 Sep 2006 07:57:15 -0500 > > > > > > > >Drop them by the local funeral home, I bet they would get it taken >care > > > of. > > > >P.S. Not really serious comment. > > > > > > > >Henry > > > > Re: Death enroute with DNR > > > > > > > > > > > > Lance, > > > > > > > > Thanks. That makes sense in your area. Unfortunately, in rural >settings > > > > there is no ME's office, and the hospitals are--shall we say--not >all >on > > > >the > > > > same page as to what they will do. > > > > > > > > I think we need a statewide protocol for this, probably a >regulation, > > > >and > > > > maybe some legislation. > > > > > > > > It's not a situation that occurs often, but it is something that has >the > > > > probability of occurring at some time for every service. We don't >need > > > >to be out > > > > here on our own trying to fashion guidelines where the law is so >vague > > > > > > > > > I will ask the state to do something on this. > > > > > > > > Gene G. > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 21, 2006 Report Share Posted September 21, 2006 1st.....Up here, I don't know of any nursing homes that do not confirm, request and validate Advanced Directives when they get a new patient. Now...may be too logical, but in my rose-tinted world, one would believe that a physician who signs a DNR is doing so for a valid reason..like, the patient has a terminal condition or is pushing 150 y/o (with poor health), and not because he calls the Grim Reaper..Chuck! BTW...Paramedics up here can pronounce in the field. We then call med control for " back up " and record keeping purposes, but essentially we are pronouncing....NO ONE likes to do it (I don't think..) Why would you need a coroner or a post for a patient with a valid DNR? Unless he is dying due to something completely unrelated to the condition that precipitated the DNR? 2nd....would not Coding a patient with a valid DNR be grounds for at least a civil suit? There was a case here about 8 years ago. Pt (65+ male with lifetime of health issues) is transported for respiratory arrest, wife is an EMT, simply didn't want him dying at home, but did NOT want CPR done if he lost his pulse. Pt had a trach...was suctioned with no result, but we were able to bag him sufficently...never got a return of respirations. She has his valid...TWO year old DNR in her hand. We reach the hospital. Pt is still not breathing, is basically gone, but has a palpable pulse of 25. We take him into the ED (small ER, closest to our town and that was protocol to transport to closest facility at that time). Dr is...well, I won't say what he is...but the wife hands him the DNR orders and specifically states " FOR the record, he does NOT want to be coded. NO CPR, NO Drugs, nothing. When his pulse goes...he's gone! " Dr. pats her on the head (no shit!) and tells her to wait in the waiting room while he checks to see if there " really is a pulse or if the EMTs are just too excited to tell for sure " ...Walks in the room, shuts the door behind him, basically in her face, and says " Start CPR and push Atropine " . The WHOLE room just looks at him....when asked why.....won't go into that.. Long story.........Wife gets a bill from the hospital and sues because she now has a $5000.00 bill for a code, with itemized drugs and the whole sad story. She wins, Doctor tries to say he was just doing what was best for the patient in his judgment and he had NO idea if that was a valid DNR or something she made up on her computer....DUH!!! He should have had to pay personal damages for such a lame defense IMO..:-) Anyway...we were told by the lawyers that had we begun CPR in the ambulance, the ambulance service would have also been named in the suit. Other side of the coin? Jules Re: Death enroute with DNR > > > >Date: Wed, 20 Sep 2006 07:57:15 -0500 > > > > > > > >Drop them by the local funeral home, I bet they would get it taken care > > > of. > > > >P.S. Not really serious comment. > > > > > > > >Henry > > > > Re: Death enroute with DNR > > > > > > > > > > > > Lance, > > > > > > > > Thanks. That makes sense in your area. Unfortunately, in rural > settings > > > > there is no ME's office, and the hospitals are--shall we say--not all > on > > > >the > > > > same page as to what they will do. > > > > > > > > I think we need a statewide protocol for this, probably a regulation, > > > >and > > > > maybe some legislation. > > > > > > > > It's not a situation that occurs often, but it is something that has > the > > > > probability of occurring at some time for every service. We don't need > > > >to be out > > > > here on our own trying to fashion guidelines where the law is so vague > > > > > > > > > I will ask the state to do something on this. > > > > > > > > Gene G. > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 21, 2006 Report Share Posted September 21, 2006 In Texas you're immune from suit for failing to follow a DNR, at least, that's what the statute says. It hasn't been tested. My dad had his last stroke 6 months before he died. We moved him 100 miles to a nursing home across the street from the college where I worked. He could not find a physician who would see him for a long time. Finally, one agreed, but would only see him in his office, which meant hauling him to the office, leaving him on the stretcher for God knows how long, and then calling EMS back to take him back. When he finally died, the NH physician refused to sign the death certificate. I had to threaten him with a lawsuit even to get the records. I would have been better off if I had called a JP to come pronounce him. That anecdote is off topic, but it illustrates the problems that can arise in just getting a death certificate sometimes. That county doesn't have a medical examiner. Only about 15 counties out of 254 in Texas do. The rest of them have Justices of the Peace, a magistrate level judicial officer, the requirements for which are a pulse and respirations. Generally these people will ask, " Do you know why he died? " I could say Fatal Familial Insomnia, and that's what they would write on the DC. If you want to commit murder by poison, just come to rural Texas. I think EMS needs some clear guidelines that are also binding on the hospitals. Gene G. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 27, 2006 Report Share Posted September 27, 2006 Gene, I don't believe that there is a legal necessity to know the cause of death in order to pronounce a person dead. As I understand it, the only requirement is that the pronouncing party (MD, DO, ME or JD) be convinced that the body in front of them is dead. Randy R. (Randy) Loflin, M.D., FACEP Associate Professor Medical Director, City of El Paso EMSS Re: Death enroute with DNR The problem is that the hospital physicians won't pronounce them because they " don't know the cause of death. " Gene Quote Link to comment Share on other sites More sharing options...
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