School of Social Work, University at Buffalo, Buffalo, New York (DPW); Department of Emergency Medicine, Albany Medical Center, Albany, New York (MRW); College of Community & Public Affairs, Department of Social Work, Binghamton University, Binghamton, New York (JMM); Department of Emergency Medicine, University of Louisville, Louisville, Kentucky (CRC); Department of Emergency Medicine, University at Buffalo, Buffalo, New York (BC).
Prehosp Emerg Care. 2022 Mar-Apr;26(2):223-232. doi: 10.1080/10903127.2020.1863532. Epub 2021 Feb 2.
End-of-life treatment decisions present special challenges for prehospital emergency providers. Paramedics regularly make value-laden choices that transcend technical judgment and professional skill, affecting the type of care, how and to whom it is provided. Changes in prehospital emergency care over the last decade have created new moral challenges for prehospital emergency providers; these changes have also accentuated the need for paramedics to make rapid and reasoned ethical judgments. The purpose of the study was to explore the decision-making process that occurs when prehospital emergency teams respond to an end-of-life call with a focus on how state authorized documents such as a Non-Hospital Do Not Resuscitate (NHDNR) or Medical/Physician's Orders for Life-Sustaining Treatment (MOLST/POLST) or lack thereof inform decision-making. This paper presents the specific circumstances that informed the need for intervention from Online Medical Direction (OLMD) framed in the perspectives and words of the prehospital providers seeking that assistance. : This study involved in-depth in-person interviews with 50 providers to elicit participants' experiences in their own words using a semi-structured interview instrument. Interviews were audio recorded and transcribed with permission. Five themes emerged that illuminated how and when OLMD was involved in emergency end-of-life decisions: Termination of Resuscitation (TOR); Family Revoked DNR; Missing Documents; No Documents and No CPR; and Unusual Situations. Participants illustrated how the decision to terminate efforts was best-supported when it was made by collaboration between the on-scene provider and OLMD. Participants described ethical dilemmas when families asked them to initiate CPR in the presence of DNR orders and cognitive dissonance when CPR has been initiated but a valid DNR/MOLST is subsequently located. The study findings demonstrate the invaluable contribution of OLMD for complex end-of-life care decisions by prehospital providers, especially when there are difficult legal, ethical, and logistical questions. OLMD provides far more than technical support.
临终治疗决策对院前急救人员提出了特殊挑战。护理人员经常做出超越技术判断和专业技能的有价值的选择，影响护理的类型、提供方式和对象。过去十年中，院前急救护理的变化给院前急救人员带来了新的道德挑战；这些变化也凸显了护理人员快速做出合理道德判断的必要性。本研究旨在探讨院前急救团队在接到临终电话时的决策过程，重点关注州授权文件（如非医院不复苏（NHDNR）或医疗/医生维持生命治疗医嘱（MOLST/POLST））如何以及在缺乏此类文件的情况下如何影响决策。本文介绍了需要在线医疗指导（OLMD）干预的具体情况，并从寻求该帮助的院前护理人员的角度和语言出发进行了阐述。：本研究采用深入的面对面访谈，对 50 名护理人员进行了访谈，使用半结构化访谈工具，以参与者自己的语言描述他们的经验。访谈在获得许可的情况下进行了录音和转录。五个主题出现了，阐明了 OLMD 如何以及何时参与紧急临终决策：复苏终止（TOR）；家属撤销 DNR；缺少文件；无文件和无 CPR；以及特殊情况。参与者说明了当现场护理人员与 OLMD 合作做出终止努力的决定时，如何最好地支持终止努力。参与者描述了当 DNR 医嘱存在时，家属要求他们开始心肺复苏术时所面临的道德困境，以及当已经开始心肺复苏术但随后找到有效的 DNR/MOLST 时的认知失调。研究结果表明，OLMD 为院前护理人员提供了复杂的临终护理决策的宝贵帮助，尤其是在存在困难的法律、伦理和后勤问题时。OLMD 提供的不仅仅是技术支持。
