The PalliEM Podcast:
Episode 5 – Engaging EMS in Palliative Care Delivery
– with Dr. Stephen Powell, MD.

Engaging EMS in Palliative Care Delivery – An Interview with Stephen Powell, MD

SPEAKERS

Justin Brooten, MD, Stephen Powell, MD

 Justin Brooten, MD  00:01

This is the PalliEM podcast, a production of PalliEM.org at the intersection of palliative Emergency Medicine. I’m your host, Justin Brooten. Today on the PalliEM podcast, we’re joined by Dr. Steven Powell. Dr. Powell is an assistant professor of Emergency Medicine at the Wake Forest School of Medicine. He’s also the medical director of Davie County EMS. His work focuses on EM resident education and EMS provider education. He has an interest in improving the understanding of the role that EMS can play in caring for patients nearing the end of life. Dr. Powell, thank you so much for joining us.

 

Stephen Powell, MD  00:36

Well, thank you very much for having me. I’m excited to be here.

 

Justin Brooten, MD  00:40

One of the reasons I wanted to have you on the podcast is I’ve appreciated seeing how EMS can be better involved with patients nearing the end of life. Palliative care, and hospice is not something that’s typically part of their EMS curriculum. What are the gaps in how EMS agencies typically respond to acute concerns with palliative care patients?

 

Stephen Powell, MD  01:01

Yeah, well, well, thank you. Yes, and, and that’s exactly it. I mean, I’ve just seen that there is a need and providing education to our EMS colleagues, because they’re in the house, they’re on the scene with people who are dying, and that have end of life care needs. And I think that that’s a tremendous area that we can improve upon and educate our colleagues with, as far as some of the gaps go, I have noticed that this is a very difficult time for families, for patients. And this is this is a tremendous responsibility placed on our EMS colleagues with very limited training as a whole on how to deal with this situation. And oftentimes, I’ve noticed that they are may not be prepared on how to deal with somebody who is dying, how to provide medications, not for life sustaining treatments, but more for comfort measures. And also just how to deal with family members that are grieving that may make decisions or feel the need to make a decision that may not be aligned with the patient’s interest or their goals of care.

 

Justin Brooten, MD  02:00

That’s really well put, I think you’re right when people call 911. Part of the reason they’re calling is because they’re panicked. And being able to decipher the family member who’s just concerned and distraught, and is asking for something to be done versus the one who’s asking for aggressive treatment, they’re not as sort of the same thing. But to the unskilled the or they may seem like they’re making the same request.

 

Stephen Powell, MD  02:21

Absolutely. And I think that’s the most important thing is to understand when EMS is called, it may be because they’re not able to get in contact with maybe their hospice team. And so this is an established hospice patient with a terminal illness. And they understand and they they’re well aware that they are dying, but when the actual process is underway, when the person is actually dying, and they’re gasping, and they’re in extremis, the family members, maybe were did not receive the education they needed, maybe they were not prepared for the actual events that are going to happen. And they panic, they may try to get hospice, they may not. And they do it, we’re always told call 911. And I think with that, with us knowing that’s going to happen, we should very much spend the time with our EMS providers to educate them on how to deal with that situation.

 

Justin Brooten, MD  03:08

Absolutely. It’s it’s ingrained in us. It’s, it’s an instinct to just pick up the phone and call 911. How do you how do you go about explaining the approach they might want to take with some of these faith patients? How do you how do you explain that to them?

 

Stephen Powell, MD  03:22

Yeah, that’s a great question. Whenever I’ve spoken with our paramedics, on the in the field who are dealing with this situation, I try to approach it from the perspective of what’s happening, and what are the expectations from the family? So, for instance, if the patient has a DNR form, what, what or what, for what reason, if they call you a mess, and what are they needing in this moment, because that’s typically what it is. And so they might need me to affirm to the patient’s family, that this is what’s happening, that the person is dying. And that’s maybe something that they feel is out of their scope, or out of their comfort level. So a lot of times, that’s what I’m providing insight into and help into. And it might even be for just things like orders. So it might be that there’s copious secretions of patients in distress, and how do we manage this, and that might be instructing them to use the kit that’s provided with them for their emergency treatment of you know, during the dyeing process, or it might be administering medications through their own supplies, within their scope of practice to help the patients. So that’s typically what the calls are for.

 

Justin Brooten, MD  04:21

Yeah, you bring up a good point. They’re not familiar with using medicines for comfort care. They’re used to using medications for treatment purposes. One of the things you brought up that I think could you some clarification, as some of our listeners, may be in physicians, and some are palliative care physicians. So could you tell us a little bit about how medical direction works, and then describe where that can bring up some challenges depending on who’s picking up the phone in the emergency room?

 

Stephen Powell, MD  04:46

Absolutely. So historically, EMS has been the Wild Wild West, you would have agencies in different states and different counties, even in neighboring counties doing opposite things. Evidence based medicine here non evidence based medicine here and it can be read by maybe a paper doc that essentially signs a form. And they let them do whatever they want to a physician that’s very involved and very experienced, that’s waiting a very good team. And so, medical direction is essential to EMS systems, and allowing a emergency medicine trained, hopefully, EMS subspecialty boarded physician provide medical direction to a County EMS system. And the reason that’s important is because these patients are brought to the ER, and hence our specialty in emergency medicine. And then, by doing an emergency medicine residency, I went on to do a fellowship and trained in how to manage an EMS system. And I provide insight and essentially medical consultation to a system to provide them with protocols for what we call offline medical control, where a patient may have chest pain, and they have an algorithm of how to address that chest pain. And then I also provide a system to allow them to have access to online medical control, or they can talk to to a physician, whether it be myself, an assistant Medical Director, or a destination hospital as well. And so whenever they call somebody that, whether it be calling the medical director or the system or director or the hospital, they’re going to and typically there’ll be speaking with an emergency physician, my goal was a medical director is to stay up to date with evidence based medicine, apply that to our County EMS system, and then provide education to our medics to make sure they’re competent. And so that’s what we really try to accomplish in the EMS world.

 

Justin Brooten, MD  06:30

When EMS calls, say the ED and talks to the general ED physician, and they’re seeking for some guidance about what to do with this patient in respiratory distress. Why might that lead to challenges for them to get instructions that that will be helpful on scene?

 

Stephen Powell, MD  06:46

Yes, that’s a great question. So it’s a working in the emergency department is already chaotic and already busy, to take the time to listen to a paramedic for very complex scenes situation like this is also and just ended up itself is very challenging, then you have variable experiences based on the emergency medicine physician in the ER that you may be talking to this may be something that’s somebody that’s been practicing for many years is very comfortable, terminating unseen resuscitation for somebody that’s been down for 20 minutes and asystole versus somebody who just started working, who doesn’t have that experience in those in that confidence. Furthermore, with EMS, and specifically palliative care stuff, they do possibly worry about a liability perspective. So they may be guiding a situation that they’re not entirely comfortable with, not personally speaking with a family, and they’re only talking with EMS providers. And so while it’s helpful, and our colleagues in emergency medicine are very well trained in this in their residency to deal with this. That’s why as an EMS physician, and specifically as a medical director, I think we have a role to play in providing protocols, offline medical control that our medics can utilize to go down an algorithm where they may not have to call the emergency room, and a process for hopefully education from myself as a medical director, or contacting me as the medical director to deal with this very special situation.

 

Justin Brooten, MD  08:06

So recently, it was right before COVID, North Carolina adopted some state EMS protocols to try to help address this. Sure. Have you had a chance to see any situations since you’ve been in practice where you’ve saw seen some of these protocols put into action?

 

Stephen Powell, MD  08:23

Sure. So that’s a good question. So the the hospice and palliative care patient is the protocol that was recently adopted and utilized by many agencies is put out by the state, and then each county can can adopt and change that. And I was actually talking to our team this morning about how we deal with this just to kind of prepare for this talk. And it seems that this is something that we use very frequently, we tried to foster a very good relationship with our own hospice team locally, it’s something that’s been very useful for our particular county,

 

Justin Brooten, MD  08:53

Can you describe some situations where this has been used just in general terms?

 

Stephen Powell, MD  08:58

Well, you know, in general, the protocols can be somewhat logical and intuitive. And what’s nice about protocols in general, from a medical direction standpoint, is that we just provide a way for the medics to do something and then have the A, okay, by essentially a physician in that way, from a liability perspective, they are covered. And I think that’s what you get out of these protocols. But the protocols to you would actually probably make real good sense, right? So for instance, is there a terminal illness? Is there a life altering chronic illness? And if there is, are they an established hospice care patient, and if they are, then you can contact the hospice service and ensure that they’re going to respond at the scene and help. And that might just be the protocol. And so sometimes it’s putting words on paper, and giving the medics an algorithm to follow. And it’s as simple as that. And so, I do think that that can be utilized pretty well, as long as we make sure that the protocols are written in a way that they can understand and are kind of consistent with standard of care and centered practice locally. Well, it

 

Justin Brooten, MD  09:59

Sounds like that helps really empower the medics to make decisions on scene that they need to make.

 

Stephen Powell, MD  10:04

I think that’s the biggest opportunity we have. I mean, the EMS system as a whole was, was designed to respond to people who having emergencies. And we’re trying to prevent them from having serious long term disability, like loss of limb or, or death, and to turn around and ask us to use our EMS system to respond to people who are dying. And our goal was not to prevent death. That’s a very difficult thing for us to grasp. But I do think that we are situated very well based on the training that medics receive to do very well at that task. And I think that we just have to make sure we’re, we’re doing it in the right way with the right education with the right people. And typically, our our local hospice team is part of that.

 

Justin Brooten, MD  10:48

What essential skills do you think EMS providers need to be able to take care of hospice and palliative care patients,

 

Stephen Powell, MD  10:54

I think they need to understand airway and how to manage airways. And from the in that regard, I’m not saying they should intervene on our postures patients having airway emergencies, but by understanding that they know what to do. And so for instance, if somebody is gasping for air, they recognize that as a sign of air hunger and discomfort, and so I think that during that training of things that they were see they should intervene upon, they could also intervene upon it in just a different way. So for instance, they may be able to give morphine for air hunger when they see that. And they may be comfortable with seeing that because of what they do. They may notice somebody who is anxious because of hypoxia, you know, we’re trained to see if somebody looks anxious, and they’re then consider hypoxia as a cause. And so they knew to get Ativan. And they know that’s a symptom of their air hunger and their hypoxia. So I think understanding how to manage an airway is important, but also how to administer pain medications and medications for calming. So often our paramedics who may be called upon to treat pain for a limb injury from motor motor vehicle accident, so there, they are comfortable using things like fentanyl, and Dilaudid. And morphine. They’re comfortable with multiple different ways of administering this as well. Similarly, for agitation, and we may have to provide some calming medications in the seat on the scene for somebody who has overdosed on a certain medication or used illicit drugs. And so they’re they’re comfortable with administering things like Versed and things like Ativan. And so I think that that’s helpful in that regards. I think another skill that maybe we don’t know, it’s hard to say it’s a skill, really, but something that they maybe have seen that we have not seen, is death, working in the emergency department, we see very terrible things, we see people that are near death, or they do die in the ER, and that’s hard for us to grasp with. But EMS personnel, they see the people that were not transported. They see the people that were dead on the scene, and they pronounced them. And I think that although it’s somewhat of a morbid thing to consider their experience and the sheer number of people that they see, like that puts them in a very unique position to help these people who are dying because they can have the the calmness the experienced to know what happens next, and that, that they made the right decision, because they know that there’s nothing they can do in that situation.

 

Justin Brooten, MD  13:12

Yes, it’s so true. And I’ve seen some pretty horrific things as an ER doctor, but some of the most horrific things I’ve seen have been when I worked in EMS for that very reason. What are some of the communication tips or guidance that you give to your medics to try to help give them some tools to enable them to deal with these situations better?

 

Stephen Powell, MD  13:30

I think that understanding the grieving process, and, you know, from talking to our team, even at Davie County, it’s not the patient that is typically the difficult part of these encounters, it’s truly the family. This is incredibly difficult on them. It’s incredibly, um, they may, they may know their loved ones dying, but to see them dying, isn’t is different into entirely and understanding that that is going to be a hard part of this call, and how to manage the family how to be firm, be confident, be caring, and empathetic. To demonstrate compassion of the situation. I think those are all things we have to consider can be a spoken words a an urban kind of nonverbal body language, touching somebody on the shoulder and telling them, you know, I’m sorry for your loss. There’s so many things that we can help with, with education. And, and I think that’s probably the key is is providing them a framework and an idea of what’s going to happen. And this is going to happen every time. So how do we manage this? And those are the things we can work on.

 

Justin Brooten, MD  14:38

That’s a good point. You mentioned having an understanding of grief. One of the things that I’ve noticed is family members, even when they are aware, like you said they’re aware that their loved ones dying. When they’re in distress. They’re still saying, you know, do something and being able to tease out the nuance of what are they really asking me for? Are they are they asking me to try to stop this process? Are they just asking me to help them deal with the gravity of the of the situation. And I think a lot of times, it’s that it’s they need to know that their loved ones being helped. And what helped means can be different things that could mean it could mean that they need to go to the hospital. And it could mean that they just need some guidance with with administering medicines for comfort. That’s hard.

 

Stephen Powell, MD  15:14

And I think that’s where EMS can play a pivotal role. Because you know, I have to teach even residents all the time Do Not Resuscitate does not mean do not treat, right, there are still things we can do and treat with our patients. But at the same time, if somebody does have a terminal diagnosis or a terminal, you evaluate them, and they are literally at the end of their life, they’re gasping for air, they have mottled skin, they’re in shock. Recognizing that as a situation where based on their their most form, or they’ve selected they do not want to be intubated, based on their most form, they did not want aggressive life saving interventions performed, then now we’re going to do it on an algorithm and empowering them to do so. And I think we have to teach that because we some, we may need to listen to the family member who says, Don’t let them die, do something, do something and you compassionately I don’t wanna say disagree with them, but compassionately educate them that this is not what we’re going to do. And we are going to honor the patient’s wishes in a respectful way to allow them to pass with dignity based on their predetermined wishes. And I think that families need that. So oftentimes, when I see patients in the ER that are dying, with a terminal illness, they need me to tell them, there’s nothing we can do, they may need me to tell them that they’ve done everything they can do, they need that personal reassurance, like you talked about, and that is such a hard thing to convey. But I think that allowing us to empower our paramedics, to teach them how to deal with these situations, is an ultimately be the right thing for our patients that are dying, that we’re responding to.

 

Justin Brooten, MD  16:52

I liked the statement, you made compassionate disagreement. That’s a good way to put this because you do you have to kind of you need to challenge it’s not just an overt denial to provide with the care they’re looking for. But you’ve got to be experienced enough to look at the situation say, we’re not going to be able to turn this ship around. Yeah, so this is what’s happening. And they,

 

Stephen Powell, MD  17:10

they want you to know that we did everything. And sometimes I try to explain it to patients too, that it we can we can do everything. And we can do things. But do they want us to do those things to them. And if they don’t, then we need to talk about a realistic outcome of this. And I don’t think that many Americans, many people in general want to die and I ICU with beeps and fluids going in and lines and things in their orifices. I don’t think they want and if they were to ever see that, they would be horrified, and I think that’s where we as physicians, we as you know, you as a palliative care physician, myself, as an EMS physician, that we can play a tremendous role in preventing that from happening because the patient does not want that. And it’s just such a hard time because we have literally seconds and minutes to talk with families to intervene, right, because if we don’t intervene on someone who’s gasping for air, who’s hypoxic and anxious, they’re gonna die. But then again, if we intervene, are we violating their goals of care? It is, it is such a challenge.

 

Justin Brooten, MD  18:22

It is you’ve got to make those decisions in seconds, and you don’t have a lot of time to go back and forth. But sometimes when you get to the core of what’s what they’re really dealing with is the distress of the of the dying process, not necessarily changing goals. But those are usually the situations where people are the most thankful, is when you actually really helped tell them what they needed to hear. And they knew they needed to hear it. But it was just tough.

 

Stephen Powell, MD  18:43

And I think taking the time to explain it is probably the biggest key because, you know, you oftentimes you’ll find that if you actually just sit down and talk with a family even afterwards about what happened and take the time to answer their questions. They’ll accept it. But if you if you walk out of the room, they’re going to be left with these questions. And we’re left with like, did we do the right thing and maybe some even some, you know, maybe they just disliked the situation and therefore disliked the provider. And that can be like me detrimental long term. I remember, one of my mentors in residency told me that, you know, I know this person’s DNR, but they’re still an intensive care patient. And, and I didn’t really understand what that meant for the longest time. But if I have somebody who’s dying in front of me with septic shock, I’m in there putting IV fluids and putting in big central lines, giving them maybe pressors antibiotics, aggressively treating them. I should be doing the same thing for somebody who’s dying. These are their last moments on Earth. I need to comfort them, I need to prepare them for this. I need to talk with them. Let them be involved. Make sure the family is sitting beside them in a chair while we’re doing these things holding their hand. Making sure that nurses are actually present in the room and providing, you know morphine and Ativan and and wetting their mouth or whatever needs to be done. And I think if we can translate it Add to the pre hospital environment to the same level of intensity. I think that the patient’s family is experienced with it. They’ll feel comfortable knowing that we were so aggressive and we were so attentive, and we cared for their loved ones so much that they will accept what has happened and they will be able to move on.

 

Justin Brooten, MD  20:16

Sometimes they just need that reassurance that the all appropriate treatments have been tried, you know, that they the opportunity to live longer, if possible, has been has been put forth. And this is something that’s now kind of out of our control. But what we can do is alleviate the some of the suffering that comes with it. Well, thank you so much, Dr. Powell. I really appreciate your responses and your thoughtfulness to all these questions and also, what you’re doing to just champion changes in how EMS handles patients with palliative care and hospice needs, that we can continue to transform the care for these for these types of patients.

 

Stephen Powell, MD  20:48

Thank you, Justin for having me and I’m a big fan of this podcast, so I hope to have to listen in more in the future.

 

Justin Brooten, MD  20:54

For more information on current topics in the fields of palliative and emergency medicine, please visit PalliEM.org