Transcript October 2010 CE: Therpeutic Comm, Death

Therapeutic
Communications;
Compassion, Death &
Dying; MAD
Condell Medical Center EMS System
October 2010 CE
Site Code # 107200-E-1210
Objectives by: Debbie Semenek, RN, EMS System Coordinator
Packet prepared by: Sharon Hopkins, RN, BSN, EMT-Paramedic
Objectives

Upon successful completion of this module, the EMS
provider will be able to:
1. Define the communication process.
2. List components of the communication process.
3. List obstructions to the communication process.
4. Identify strategies for developing trust and
rapport with patients.
5. Define interpersonal zones.
6. Identify strategies used during the interview
process with patients.
Objectives cont’d
7. Describe elements of patient caring.
8. Describe the unique challenges for EMS
personnel in dealing with themselves, adults,
children and special populations related to death
and dying.
9. List the 5 predictable stages of loss by
Elizabeth Kubler Ross.
10. State the components of the State of Illinois
Advanced Directives.
Objectives cont’d
11. Review the Region X SOP “Withdrawing
Resuscitative Effort”.
12. Review the MAD usage.
13. Review documentation components for
discussed conditions.
14. Actively participate in case scenario
discussions.
15. Successfully complete the post quiz with a
score of 80% or better.
16. Given the equipment, demonstrate use of
the MAD device.
Communication

Just an exchange of symbols:

Written, spoken, gestured
Components of Communication

A sender – creates the message
 The message is sent
A receiver – interprets the
message sent
Feedback – response is given
to the message received
Failed Communications

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Prejudice – toward patient or situation
Lack of empathy – identifying with and
understanding another’s situation, feelings,
motives
Lack of privacy – may inhibit responses
External distractions – TV, traffic, crowds
Internal distractions – thinking about other
things
Key Point

Improve communication skills with:
PATIENCE
 FLEXIBILITY
 RESPECTFULNESS
EVIDENCE OF COMPASSION


Once trust is established, rapport follows
 Avoid false promises – they violate your
patient’s trust

Building Trust & Rapport

Use the patient’s name


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Breaks down some barriers
Ask the patient how they want to be addressed
To remember names:

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
Say the name out loud three times in the 1st minute
“See” the name in your head
“Feel” yourself writing the name in your
imagination
Trust and Rapport

Voice
 Watch your volume, speak quietly in low
tones
 Check your pitch – high voices are harder to
hear
 Watch your rate of speaking
 Use a professional, compassionate tone
 Avoid sarcasm, irritation, anger
Trust & Rapport

Explanations
 Explain what you are doing
 Explain why you must do something
 Eases patient’s anxiety

Often best to give a short explanation immediately
prior to the procedure
 Less time for the patient to dwell on what will
be done
 Less time for the imagination to roam
Trust & Rapport

Facial expressions


Keep a kind, calm facial expression
Keep a “poker” face

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Convinces the patient you can handle the situation
Smiling when speaking puts a more pleasant tone
in your voice
Interpersonal Zones

Intimate zone – 0 – 1.5 feet
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Personal space – 1.5 – 4 feet
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Visual distortions
Best for assessing breath & body odors
Used for much of patient interview and assessment
No visual distortion
Voice is moderate
Social distance – 4 – 12 feet
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Impersonal business transactions
Personal interview in dangerous situations
Interviewing Techniques

Goal:
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Identify chief complaint
Determine circumstances causing the emergency
Determine the patient’s condition
Achieving the goal:
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Asking questions
Observational skills
Effective listening skills
Interviewing Techniques

Open-ended questions

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Questions that permit unguided, spontaneous
answers
 “What happened that you needed to call 911?”
 “What seems to be the problem?”
Benefit
 Patient responds in an unguided way
 May include information that indicates
additional assessment of patient
 Chief complaint can drive direction of rest of
the interview
Interviewing Techniques

Leading questions
 Question framed to guide the direction of
the patient’s answer
 “Are you having chest pain?”
 Problem –
 Could miss a serious problem by
refocusing the patient away from their
true chief complaint
Interviewing Techniques

Direct or closed questions
 Requests specific information
 “Are you nauseated?”
 Answers fill in information generated from
open-ended questions
 Answers crucial questions when time is
limited
 Helps control overly talkative patients
Interviewing Techniques

Ask one question at a time


Designate one person to ask questions


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Allows patient to finish answering one question
and to complete their thought
Confuses patient when multiple people ask
questions
 May not be clear which person/which question
the patient is responding to
Listen to the responses
Do not interrupt
Interviewing Techniques

Use of language
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Use words the patient understands
 “pee” instead of “urinate”
Avoid slang or jargon
May need to phrase the words multiple ways for
the patient to understand the question
Remember that children are literal, concrete
minded
 You say “I’m taking your blood pressure” and
the child wonders where you are taking it to
Patient Caring

“People will seldom remember what
you did or what you said. But they
will almost always remember how
you made them feel.”
Cab Driver, Boston
What EMS does…

We fix problems

Technical stuff
Splint
 Bandage
 IV’s
 Drugs
 Etc.

What else we do….

We fix people
Family concerns
 Non-medical needs
 Emotions
 Comfort
 Being a friend / advocate

EM“S”

Service
 Must have a natural ability to like people


We encounter people at their worst – they are in
crisis
If you don’t want to be there and you don’t want to
take care of them…they will sense that, so…
…consider a different profession!

Remember, an emergency is defined by its
owner – not by us

Don’t underestimate the patient

People are easily overwhelmed

They don’t know where to
turn, so they turn to us

It does not make them stupid

It is not a waste of our time…
Who Do We Serve?

Define who all of our customers are


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In-house, department members
Vendors supplying the department
Other village/city/governmental departments
Hospital staff
Our patients
Our patient’s families
Who else???
What’s the message???

Regard everyone
as a
customer.
Be Effective

To be effective with your technical skills you
must:

See the patient as more than the problem,
complaint, that they present

They are customers that reach out to you in the
worst moment of their lives
Be Effective

Explain every phase of treatment to your patient

Let them know what to expect
 Ask permission before a procedure
 When you can accept a ‘yes’ or ‘no’ answer
 When there shouldn’t be a choice (ie: necessary
IV), avoid phrases like “Can I start this IV”
 Give the choice, instead, possibly to the IV site

Give them an opportunity to report changes


Patients are highly aware of a caregiver’s
attitude – whether positive or negative.
If you show honest concern, the patient will
sense it.
Caring…

We must be people who can enjoy serving
others for 30 years and sell them the real deal


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Not every call is dramatic
Burnout is a possibility
 What are your expectations?
Our role in a patient’s life is more than just a
moment
Caring…

Habitually use peoples’ names
 Hi. What is your name?
 Introduce yourself
 Ask how the patient wants to be addressed
 Connect with the person – not the problem
 Smile
 Be respectful
 Maintain eye contact
 Immediately puts you in touch with their
emotional state and mental status
Caring…

Remember people have families / significant
others

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Families are important to us
 Healing
 Informative
 Supportive
DO NOT toss a family member/significant others
aside so we can do our work
 May be the last time the patient is seen in a
comfortable setting

Understand that physical comfort, fear and
embarrassment are important to our patient
 Need to be vigorously addressed
 Pain control
 Keeping a patient warm / cool
 Providing emotional comfort
 Maintaining modesty / dignity
Families and Death

The reality of death is:
It’s traumatic
 It’s stressful
 For us, too
 It’s a situation that is permanently imprinted
 Everything that is heard and seen and will
be remembered

Delivering the News of Death


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EMS often in the position to have to deliver
news of a death
No script can cover all situations
Each scene must be assessed as well as the
persons involved

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Then determine safest and most compassionate
way to deliver sad news
Provide a private area for sharing information
Deaths – Phrases to avoid…
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“I know how you feel”
“I understand”
“You’re so strong”
“Get on with your life”
“It was God’s will”
“They led a good life”
“It could have been worse”
Caring…Two

roads to take
The high road

Compassionate
To each other
 Conveying caring / offering condolences


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Giving permission to grieve

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Explaining actions / inactions
Denial, anger, bargaining, depression, acceptance
Offering continuing support

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Clergy
CISM (CISD # 1-800-225-2473)
Counselors
Friends
The low road…

Tough / abrasive

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Don’t talk to anyone, keeping them away
“Death does not phase me” attitude
Being cold
Being distant
Tough is not professional

Dealing with the difficult situation

Families who are able to spend time with the
body or dying person do better emotionally
in the long run
“There is an image of the loved one looking
worse than they really are when the body can’t
be seen.”

If the image is bad, give family the option
What to say & do…
It’s OK to share that it’s hard for you
 Let touch convey caring
 “I wish so much you had them back”
 “I see how painful this is for you”
 Ask to hear about their loved one
 Be a good listener

Stages of Loss

Experienced in any loss


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
Death
Relationships
Jobs
EMS is exposed to a multitude of emotional
responses

We don’t always see people at their best is why we
always need to function at our best
Stages of Loss


5 predictable stages
 Denial – “not me”
 Anger – “why me”
 Bargaining – “okay, but first”
 Depression – “okay, but I haven’t”
 Acceptance – “okay, I’m not afraid”
Stages can progress in any order and time
frame for each is individualized
Denial



Inability or refusal to believe the reality of the event
Used as a defense mechanism
 Person can put off dealing with the inevitable
If death is discussed, use the terms “dying, died,
death, dead”
 Use of “passed on, left us, gone away” can be
misinterpreted
 Avoid statement’s of “God’s way” or relief of pain
or other subjective assumptions
Anger



Really a frustration over inability to control
situation
Anger can be focused on anyone or anything in
their pathway
Watch for safety issues
Bargaining

Patients may try to “make deals” to put off or
change the inevitable

“I promise to …(go to church, be kinder, donate
my money…) if…(the diagnosis is wrong, the
disease isn’t so bad, it was mistaken identity)
Depression

Patient experiences a variety of feelings
 Sadness
 Mourning
 Retreats into self/private world
 May lose interest in self care
 Bathing issues
 Non-compliance with medical care
Acceptance
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Patient may or may not reach this stage
May achieve a reasonable level of comfort
with situation
Family may need more support at this point in
time
EMS and Patient Resources
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Department peers
Department chaplain
Family members
Religious affiliation
Hospital services patient is connected to
Hospice if patient is enrolled
Others?
Components of a Valid DNR
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IDPH Uniform DNR Order form which has not been
revoked
Name of the patient
Name and signature of the attending physician
Effective date
The words “DO NOT RESUSCITATE”
Evidence of consent:
 Signature of the patient or their legal guardian
 Signature of durable power of attorney for Health
Care Agent
 Signature of surrogate decision maker
State of Illinois DNR Form

Did you know?


Form is acceptable reproduced in any color
 Acceptable components must be present
State of Illinois is only State form acceptable
 If patient presents an out of State form, CPR
must be initiated
 Call Medical Control ASAP to request
termination of CPR based on presence of out
of State DNR form
IDPH DNR Form


Gives an individual the additional freedom to
decide what medical treatment fits his or her
beliefs and wishes
Differentiates between “full cardiopulmonary
arrest” and a “pre-arrest emergency”
Pre-arrest Emergency

When breathing is labored or stopped but the heart is
still beating

2 options to choose from:
 “Do Attempt Cardiopulmonary Resuscitation”
 “Do Not Attempt Cardiopulmonary Resuscitation”

There is also a space available for an individual to
give “other instructions” regarding application of the
DNR Order under certain circumstances:
 Accidents
 Surgery
 Choking
IDPH DNR Form

The order is still considered valid if the back
of the form has not been completed.

The order can be revoked

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
Writing “VOID” in large letters across the front of
the form revokes the form
Form can be torn/shredded/destroyed
Can be revoked by the individual or their legal
representative
Durable Power of Attorney for
Healthcare (DPOA)


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Written record (multiple pages)
Allows patient to choose an agent who will
make healthcare treatment decisions when the
patient cannot
Applies whenever the patient can no longer
make treatment decisions for themselves
Provides “agent” with power to provide
consents and refusal for any type of medical
care or treatment
DPOA Form
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Completed by any adult with sound mind
Must be witnessed
Agent’s signature is not mandatory
Can be revoked at any time
Downside for EMS

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Less familiar to EMS than the DNR form
Lengthy document to review in critical situation
Living Will
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Written record
Expresses care patient would choose during a
terminal injury or illness
Specifies care patient would want / not want
Cannot be used if the patient is capable of
making decisions
Is not recognized by EMS

If presented by a Living Will document, begin
appropriate care and contact Medical Control
Region X SOP
Withdrawing Resuscitative Efforts
Contact Medical Control
while continuing patient care
⇓
Report events of the call including estimated
duration of cardiac arrest
and treatments rendered.
⇓
⇓
Reaffirm the following:
• Patient is normothermic adult
• Patient experienced an unwitnessed arrest
• Advanced airway secured and IV/IO
placement confirmed
• Patient remains in arrest despite aggressive
BLS and ALS
treatment modalities following appropriate
SOPs
• At least two full medication rounds have
been administered
⇓
SOP cont’d
⇓
If the Physician orders termination of efforts,
note the time of death and the physician’s name
on the run report.
Notify Coroner or Medical Examiner.
NOTE: Only a physician may make the
determination to withdraw resuscitative efforts
⇓
Review - MAD


Mucosal atomization device
Tool to deliver medications via nasal route
 Medication atomized into tiny particles
 Nasal mucosa highly vascular
 Immediate absorption into bloodstream
 No delay in gaining access
MAD
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
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Syringe can be filled as needed
Tips are removable
Deliver medication in divided doses

Maximum of 1 ml per nares
MAD
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Insert device into nostril and
make firm seal
Hold head steady
Aim tip of MAD towards same
side ear
As quick as possible deliver
medication
Divide dose volume equally
into both nostrils
Max volume 1 ml per nares
Documentation MAD

Document in the usual manner for medication
administration
Dose route indicated is “inh”

Example:
 1020 - Narcan - 2mg - inh
Include response to intervention in comments


Case Scenario #1


EMS is called to a location for a person with
shortness of breath
Upon arrival
 Patient conscious, in respiratory distress laying in a
hospital bed
 History lung cancer, in hospice
 Family states the patient has a valid DNR and
produces form
 Family requests transport but no other care
What are you going to do?
Discussion Case Scenario #1

1. Who speaks for the patient at this time?

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
Patient is conscious
Patient has a valid DNR
Patient speaks for themselves
2. Is it appropriate to withhold care because
the patient is in hospice?
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What is the purpose of the DNR?
When does the DNR become “active”?
REMEMBER…
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DNR means


Doesn’t mean “Do Not Treat”

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
“Do Not Resurrect”
Provide care based on signs, symptoms and
general impression
Provide oxygenation, pain control, medication, etc
If it were your family member, how would you
want them to be treated?
Case Scenario #2

EMS arrives on the scene and the patient is
triple 0 (0-0-0)
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No evidence of foul play or trauma
The patient was found by the family just prior
to the call
The family states the patient has a DNR; the
patient would not want to be “worked”
Discussion Case Scenario #2


What should be your first approach at the scene?
 Assess the patient (ABC’s)
 Request to see the DNR form
If the DNR is not presented, how do you proceed?
 CPR must be initiated until a valid DNR is produced
 Once a valid DNR is produced, contact Medical
Control
 Give report
 Be specific and ask for what you want
 With the valid DNR form in hand, “can we
stop CPR?”
Discussion Case Scenario #2

Once CPR is started, when can EMS stop
CPR?

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When patient is resuscitated
When a physician directs you to stop
When there is someone to take over
When you are exhausted and there is no one to
relieve you
Document name of physician ordering CPR to
be stopped
Document time CPR was stopped
Case Scenario #3
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You are called to the scene for a 27 year-old
patient who is unresponsive at work
No history of trauma
Last seen 3 hours ago
102/56; P – 86; R – 4; pupils constricted
AVPU – responds to painful stimuli (purposeful)
GCS – 2/2/5 – 9
Describe further assessment needed and
describe interventions taken
Discussion Case Scenario #3
Immediate problem is airway
 What techniques could be used to open this
airway?

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
In absence of trauma, head tilt - jaw thrust
In presence of trauma – modified jaw thrust
What interventions could be used to maintain
an open airway?



Oropharyngeal in the absence of a gag reflex
Nasopharyngeal with or without a gag reflex
Intubation with conscious sedation
Discussion Case Scenario #3

How do you address the breathing problem?
(respiratory rate 4 per minute)

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
Maintain an open airway
Augment the respiratory rate to ventilate the
patient once every 5 - 6 seconds (has spontaneous
heart beat)
 Use BVM
 Have suction available and ready
Now trouble shoot why the respiratory rate is a
problem
Discussion Case Scenario #3

Further assessment detail:
 Blood sugar level - 86
 EKG monitor
 Sinus rhythm
 Consider need for 12 lead EKG based on data
 Patient assessment
 Lead II rhythm strip
 General impression
 Physical assessment
 No signs of trauma
 No evidence of drug paraphernalia
Discussion Case Scenario #3


Why does this patient have an altered level of
consciousness?
Think:
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A – acidosis, alcohol
E – Epilepsy
I – Infection (brain, sepsis)
O – Overdose
U – Uremia (kidney failure)
T – Trauma, tumor, toxins
I – Insulin – hypo or hyperglycemia
P – Psychosis, poison
S – Stroke, seizure
Discussion Case Scenario #3

Possible drug overdose

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

Altered level of consciousness
Pinpoint pupils
Depressed respirations
Intervention
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Support airway (BVM in this case)
Administer Narcan
Obtain blood glucose level
Be prepared for vomiting
Discussion Case Scenario #3

Narcan

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
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Narcotic antagonist
Dose 2 mg IVP
Repeated every 5 minutes as needed to achieve
desired effect
Maximum dose total 10 mg
Routes
 IVP/IO
 Inhalation (Inh)
Discussion Case Scenario #3

What is maximum volume for each nostril
using the MAD?



1 ml
Divide total volume between each nostril
 Increases absorption surface area
What are “desired” effects of Narcan?


Improvement in level of consciousness
Improvement in ventilation rate and depth
Narcan

Does the patient have to be awake and talking?
 Is that the “desired” effect?
 NO!!!!
 For combative patients, why would you
want them totally awake?
 Goal is to improve ventilations
Narcan cont’d

Remember with narcotics and Narcan
 Narcan is short acting
 Once patient improves ventilations, the
narcotic influence may depress ventilations
again when Narcan wears off
Case Scenario #4

Altered perceptions



Have one member wear distorted glasses
Have second member review the release form or
other document and ask the “patient” to review and
sign
Discuss as a group the distorted perception
experienced
Case Scenario #5

Altered perceptions



Have one member of the group muffle their
hearing
Have a second member talk to the “patient” and
give the “patient” commands to follow
Discuss as a group the distorted perception
experience
Final Comments….


Consider how and what you are
doing looks to others.
…and what
you say!
Some more to think about
Treat all patients with gentleness
 Provide a smooth ride
 Always tell the truth
 Count your blessings


Always be nice –
treat everyone with respect, kindness,
patience, and consideration.
Bibliography
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
Bledsoe, B., Porter, R., Cherry, R. Paramedic
Care Principles and Practices. Prentice Hall.
2009.
IDPH Uniform DNR Order Form. PO 335136
100M. 5/05.
Region X SOP, March 2007; amended January
1, 2008.
Steingart, J. Chief, Countryside Fire Protection
District. Patient Caring. 2010.