A Valid POLST, a Demanding Son, and a Hospice Line on Hold
You are dispatched at 02:10 to a home for a 79-year-old woman with metastatic pancreatic cancer and a valid state POLST form documenting 'Do Not Attempt Resuscitation' and 'comfort-focused treatment only - no transport.' She is cachectic, drowsy, with a respiratory rate of 36, SpO2 82% on room air, and loud gurgling respirations. She will squeeze your hand but cannot answer yes or no reliably. Her son, who lives with her but holds no healthcare power of attorney, insists she be 'put on a machine and taken to the hospital - she's just dehydrated.' The hospice nurse is not on scene and the on-call line puts you on hold. A daughter arrives by phone and says her mother 'never wanted any of this.'
1. What governs your actions, and what do you do in the next ten minutes?
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What governs
- A valid POLST is a medical order, not an advance directive and not a discussion. It travels with the patient and it binds EMS and transport clinicians. It directs me to withhold resuscitation and to provide comfort-focused treatment only. It also directs no transport.
- The son's authority: he does not have healthcare power of attorney, and even if he did, an agent cannot override a valid order in the field. The patient's own expressed wish, memorialized in the order, governs.
- Her confusion does not automatically revoke the order. She is hypoxic and hypercapnic; that is not decision-making capacity. But she is not incapable of expressing a wish either - if she were clearly and repeatedly asking to go to hospital, that would be a revocation and I would act on it. Test it with yes/no questions she can answer reliably: 'Are you comfortable?' 'Do you want to stay home?'
Next ten minutes
- Treat the distress. Opioid for air hunger - morphine 2-5 mg IV/SC titrated every 10-15 minutes to a respiratory rate and work of breathing she is comfortable with; dyspnea is a subjective symptom and the target is her comfort, not a number. Glycopyrrolate 0.2 mg SC or scopolamine for the gurgling. Reposition, fan, oral care, cool cloth.
- Oxygen at 2-4 L by nasal cannula only if it visibly comforts her; it will not change her trajectory and masks and tubing can distress a dying patient.
- Do not suction deeply and do not start an IV beyond what comfort medication requires.
- Call medical control / your on-line physician while you are waiting on hospice. A family conflict with a valid order is exactly the indication for a real-time physician consult, and it protects the crew as much as the patient.
2. The son is escalating and threatening to call the police. Give the specific language you use with him, and what you do if he does not back down.
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Framing
- He is not the villain in this room. He has been watching his mother die for months and he is being asked, at 2 a.m., to accept a piece of paper over his instinct. Address the grief before the document.
Specific language
- Start with agreement: 'You are right that she is dehydrated, and you are right that she looks terrible tonight. I am not going to pretend this is not happening.'
- Separate the order from the abandonment he is hearing: 'The form your mother signed is not saying we do nothing. It is saying we do everything except the things that would hurt her at this stage.'
- Put the question back to the patient, not to the form: 'Tell me about her. What did she say when she filled this out?' Almost always he has a story, and the story is the same as the document.
- Be explicit about what you can and cannot do: 'I cannot put a breathing tube in her or take her to a hospital against this order. What I can do, right now, is make her breathing easier. Will you help me do that?'
- Ask him to be part of the care - holding her hand, cool cloth, positioning. Grief that has a job is grief that stops escalating.
If he does not back down
- Do not argue, do not raise your voice, and do not leave the scene until the situation is resolved or you are unsafe. Call medical control and, if there is a credible threat to the patient or crew, request law enforcement for scene safety - not to remove him from his mother's bedside, but to keep the situation controlled.
- If law enforcement orders transport, transport with a comfort-focused plan and document who ordered what and when.
3. What exactly do you document, and how do you close the loop with hospice?
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Documentation of the order
- The existence, date, and exact content of the POLST; that it was reviewed on scene; and where it was found. Photograph it or include a copy with the run report if your system permits.
- The patient's own responses to your yes/no questions, verbatim if you can. Document that she was unable to participate in a full capacity discussion and why (hypoxia, hypercapnia, drowsiness).
- The son's request, in his words, and your response. That he is not the healthcare agent.
- The daughter's statement.
Documentation of care
- Every medication, dose, route, and time, with the indication and the response - comfort-focused care still requires a full medication record.
- Vital signs, oxygen delivery, positioning, and a note about comfort at intervals ('respiratory rate 24, no accessory muscle use, appears resting after 2 mg morphine at 02:34').
- The time of each attempt to reach hospice and medical control, and the eventual outcome of those calls.
Closing the loop
- Leave a written handoff for the hospice nurse: what was given, when, the patient's status, and what the son was told.
- Notify the on-call hospice agency or medical examiner per local protocol when a death occurs at home under hospice care - but confirm your agency's requirement first; many hospice deaths are handled by the hospice, not by EMS.
- Debrief the crew. A scene like this generates as much distress in the clinicians as in the family.