Here’s the email I received about the ethics question regarding transfer of care. I cover this topic in part 1 (episode 48) and part 2 (episode 49 — next week).

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Jamie,

This happened to me last month and I’ve been asking around trying to get other people’s opinions about what they would have done, so let me know what you think and feel free to put it on the show…

The EMS I’m working for (name removed) also does non-emergency transportation for the hospital. We had a patient about two weeks ago that we were to transport to hospice after being discharged off of a treatment floor. We transferred the patient to our stretcher and began the transport to hospice when the patient began to exhibit signs of respiratory distress. Now, herein lies the ethical dilemma:

1. The patient’s file contained a DNR, but not with a signature from a responsible party. The DNR was “confirmed” by an RN talking to someone over the phone. It was also not co-signed by another RN or MD.

2. The patient was exhibiting moderate to severe distress, including multiple brief periods of apnea, but was not in a resuscitation situation.

3. I made a judgement call to return to the hospital’s ER to have the patient re-evaluated, per our protocols, which was agreed to by both my partner and our supervisor after talking to him on the phone for on-line control.EMSAmbo.jpg

4. The ER sent us right back up to the treatment floor without any other treatment, and that began an argument between the nursing staff on the treatment floor and my crew. The nurses on the treatment floor said that the MD attending the case has expressly instructed that the patient was to “leave and leave now” for undisclosed reasons, and that they ensured she was stable before we left.

My partner and I felt that this patient was not dynamically stable and needed to be re-evaluated before transport. We then transferred the patient back to a room on the treatment floor and left the floor. Our supervisor informed us about 10 minutes later that we were to meet him on the floor and we would re-evaluate the patient’s condition to determine transport options. We met our supervisor and completed a re-eval of this patient, only now being told by the RN attending that the respiratory condition of this patient was normal and not an anomaly.

Our supervisor then indicated that he was okay with the patient being transported if we were. My partner and I agreed that we would again attempt transport, but if the patient’s condition worsened, that we were going to return to the ER for stabilization per our protocols and NOT attempt a third transfer.

The nurse was hesitant to agree to this, but eventually did and we were lucky enough to make it to the hospice center without an incident. My partner and I were both very relieved that the patient did not die in the back of the ambulance, but we were at a loss as to why a transfer would be scheduled the day before Thanksgiving in the evening, which is prime rush hour in our primary service area. The lack of concern for the patient’s well being was a little unsettling as well.

I couldn’t help wondering if there was a better way to handle this situation and I’m curious to see what you think.

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I want to thank listener Marc for his time presenting this scenario to me to discuss here on the show. I hope that more of you send in your comments and questions in so that others may participate in the discussion. Feel free to leave a comment below with your thoughts about this particular call or your own transfer issues.

Jamie

the Podmedic

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