Paramedics struggle to navigate end-of-life care decisions

Transferring from a nursing home to a hospital during an emergency is one of the most stressful and dangerous times for residents, especially if they don’t really want to receive the emergency care. But incomplete or missing documentation on a resident’s end-of-life care choices often leaves paramedics and other staff in the lurch—and results in plenty of transfers that may not be desired simply because caregivers and administrators would rather not take the risk, says an article published in Emergency Medicine Journal.

The article’s British authors surveyed paramedics within the English National Health Service Ambulance Trust to learn what factors influenced the decision to transport nursing home residents and how decisions are made when the resident’s wishes aren’t clear.

“Paramedics identified difficulties in understanding nursing home residents’ wishes,” the authors wrote. “When a patient no longer had the capacity for decision making, paramedics’ reasoning processes were aligned to best interest decision making, weighing the risks and benefits of hospitalisation. Paramedics found it challenging to balance patients’ best interests with pressure from others: nursing staff, patients’ relatives and colleagues.”

Although the British exploration didn’t involve a large sample pool, the paper does raise important issues for the United States, too. Documentation of end-of-life wishes in American nursing homes is usually lacking and often limited to the realm of resuscitation. While many American nursing homes proactively urge residents to document their wishes via the Physician Orders for Life Sustaining Treatment (POLST) form, it isn’t required.

In addition, many people erroneously assume that an advance directive is all that’s needed, or that an advance directive and a POLST form are the same thing. The advance directive expresses wishes for future care, not current care—and it doesn’t provide instructions for emergency medical personnel, notes the POLST website. Educating residents and families on the importance of POLST documentation as a companion to the advance directive is key to closing loops in unnecessary transfers.

But, when it’s 3 a.m. and there’s an emergency, most skilled nursing facilities will choose to transport. “I am sympathetic to what a hard position they are put in,” Kevin Biese, who leads the American Geriatrics Society’s emergency medicine collaborative, told Reuters. “For cultural reasons, for liability reasons and for lack of resources, it is really hard for nurses at nursing homes in the U.S. to keep patients at the facility.”

Pamela Tabar

Pamela Tabar was editor-in-chief of I Advance Senior Care from 2013-2018. She has worked as a writer and editor for healthcare business media since 1998, including as News Editor of Healthcare Informatics. She has a master’s degree in journalism from Kent State University and a master’s degree in English from the University of York, England.