The call is for a sudden death; mother took her last breaths according to the son, and does not wish to be resuscitated. They send us in a non-emergency mode. I tell my partner we should probably be going lights and sirens until we know what is going on. He radios dispatch and they say okay.
I know that something is going to be funky when we get there, and when we come down the street and I see no police cars out front, I let out my breath and say to myself, here goes.
I go up the steps carrying the monitor and house bag with my meds and intubation equipment. A large man with tears in his eyes meets us at the door. He is talking on his cell phone. “She stopped breathing about ten minutes ago,” he says to whoever is on the other end, “the police have just gotten here.”
“What’s going on?” I say, trying to get him to focus on me because I know I am going to have to make some split second decisions.” He doesn’t even know I am a paramedic and not the law officers he was expecting.
“My mother-in-law stopped breathing. It was her time. She hasn’t been well, but she went peacefully.”
“Is she a DNR?”
“Is she a do not resuscitate?”
“Yes, I was talking to her yesterday, the visiting nurse was here and she was having trouble with breathing and the nurse wanted her to go to the hospital, but she said no more, she wouldn’t go. She said it was her time to go. She was ready.”
“Papers.” I said, “Do you have DNR paperwork for her?”
“Yes, they are in the safe.”
“Can you get them for me?”
“It’s locked. I don’t have the combination. My wife is coming. She’ll be here in about ten minutes.”
I know that he has no idea of the dilemma I am facing. We are taught that without the signed Do Not Resuscitate (DNR) paperwork, we have to try to resuscitate the patient.
“This is a legal thing,” I say. “We need the paperwork or else we’re obligated to try to revive her.”
“No, no, don’t put her through that that. Don’t do that to her. She was ready to die. It wouldn’t be right. She doesn’t want it.”
“I don’t want to do it either. I’m just trying to explain, there are some cases where one family member might say one thing and another something different.”
“This isn’t one. Don’t do it.”
“Where is she?
“In the bedroom.”
“Tell me more about her history,” as I start toward the bedroom. “Does she have cancer?”
“She had breast cancer, but she’s been getting fluid in her lungs. She said yesterday she didn’t want to go to the hospital. I was talking to her like I’m talking to you.”
The woman lies on the bed in pajamas. She looks dead, still, her face drained of color. I touch her forehead. It is hot – not cold or cool – hot like a fever. She isn’t breathing. She looks peaceful – looks well cared for – loved. There is a small glass of orange juice by the bedside.
I don’t want to work her, and I already know I’m not going to work her – I’m just not, but still I need to work through the legal morass.
“I’m going to have to call my medical control to get permission not to try to resuscitate her,” I tell the man as I place the leads on her.
“She doesn’t want anything done.”
“I don’t have the authority,” I say. “I have to call unless you have those papers.”
“My wife is on the way.”
I look at the monitor. I see a rhythm that startles me until I recognize it is a pacemaker. It is not as easy a sight as asystole.
I hear the police officers coming in. The man turns to talk with them. I hear them commiserating with him, saying they are sorry for his loss.
For the first time I put capnography on patient I am considering presuming to document the apnea and just to do something else while I formulate what I am going to say to my medical control physician. The capnography shows a flat line – apnea. There is no number reading, and then all of a sudden I see the number 7 pop up on the screen. It again startles me. It’s not a great number, but any number is a sign of life. It puzzles me as there is no wave form. It is not until later that I guess that it represented some gas passively escaping from the stomach.
I go out to the living room where the police and man are now talking. “Here’s what’s going to happen,” I say. I’m going out to the ambulance to call the ED doctor and get permission to presume. If they say its okay, then I don’t have to do anything.”
“Why do you have to do that?” the man says. “You didn’t do that when my father-in law died. You just called him dead.”
“Well we can do that is they are cold and stiff -- not if they are warm. There are legal criteria we have to follow."
“So I am supposed to sit her with her and wait for her to get cold before I call?”
“I don’t think it is going to be a problem,” I say, “It’s just something I need to do legally. I’m with you I don’t want to work her.”
“No one is going to do anything to her,” he says now, a hint of anger in his voice.
“I’ll be back,” I say.
Out in the rig, I call the hospital. I ask for the doctor’s medical control number and the nurse says I can get it when I get to the hospital. I was there earlier today and I saw two new doctors I had never seen before. This is not a good omen.
“I’m on scene with a 95-year old female, history of cancer, pulseless and apneic, who took her last breaths about fifteen minutes ago according to her son-in-law, who says she did not want to be resuscitated. They have DNR papers, but they are locked in a safe and the person with the combination won’t be here for another fifteen minutes. I would like permission to withhold resuscitation.”
There is a short silence, and then a question. “What is your ETA?”
“ETA? I’m on scene with a 95 year old pulseless apneic patient with a history of cancer. The family says the patient is a DNR, but the papers are locked in a safe. They will be able to open the safe in about ten minutes. I’m requesting permission to presume the patient, to not start CPR.”
There is a long silence.
My partner has come out. He says, “The man just told the cops he will fight anyone who tries to resuscitate her.”
Finally the hospital comes back on. “Are the papers legally signed?”
“They are locked in a safe,” I say, and then repeat what are usually the magic words, “This is a 95 year old with cancer. The family says she is a DNR, but the papers are in the safe and the person coming with the combination won’t be here for another ten minutes to open the safe. The family says she did not want to be resuscitated and now the son is threatening to attack anyone who tries. I’d like permission to presume.”
More silence, and they, “Okay, provided you stay until you can verify the papers.”
I repeat the order and then go back in the house.
The man looks at me in the way a man in a bar might look at another man with whom he has just had a serious confrontation, looking at me to see if it is over or if we will have to take it outside.
“I got permission,” I say, “But I can’t presume until I see the papers.”
“She’s on her way,” he says.
I hear a commotion at the back door and a crying woman comes in. The man talks with her and then he says to me, give me a minute and he and the woman go into the bedroom. I wait a moment and they come back. He has some papers in his hands. He hands me the papers. Dated almost ten years ago, it is a signed superior court paper – the jist of it says “ I, (blank) of sound mind and health, request that no heroic measures by taken should I fall ill…I do not wish to have CPR, etc.” It isn’t the official DNR, but it meets its purpose in my book.
I nod. “Okay.”
I go back in the room and look at the patient. The pacemaker has stopped now. It is flat line.
“A peaceful way to go,” my partner say. He holds a flowered sheet that he spreads over the patient up to her neck.
Out in the living room I tell the cops the time of presumption and give them my name and date of birth per protocol. I then approach the man, and say, “I’m sorry for your loss, and sorry for any apprehension I may have caused.”
We shake hands. “Thank you, that’s all right. I know you are just doing your job, but….” He looks me dead in the eye, my hand still gripped firmly in his. “You and I would have been wrestling.”
“I understand,” I say.
I walk out of the house, the monitor over my shoulder, in my hand the house bag with unopened intubation and med kits.
If he had fought, I would have let him pin me.
Postscript: Two days later, I read her obituary. It says she died "peacefully at home."